When frail older people present to hospital emergency departments, the decision about whether to admit them has enormous consequences. 

For some, a hospital stay is essential, but for many others, remaining in their homes with the right support leads to better outcomes, greater independence and a better quality of life.

The Front Door Frailty (FDF) program, now underway at Royal Darwin Hospital and in the surrounding community, is designed to meet this challenge head-on. 

The program has two tightly linked aspects—a specialised emergency department team and a community frailty service—that work together to support older Territorians to remain safely at home wherever possible.

Physiotherapist and clinical team leader in the Royal Darwin Hospital emergency department (ED) Alex Young says the FDF model fills a critical service gap. 

Alex Young.

While the team is still relatively new, it has been drawn together largely from existing hospital allied health staff. 

The team will be expanded to include a discharge planner and a specialised nurse; recruitment for both roles is currently underway.

‘Historically, when we were trying to discharge people from the ED, there was no safety net at home—you were discharging to not
much,’ Alex says. 

‘Now, the fact that a physiotherapist, occupational therapist, dietitian or speech pathologist can quickly go and do a home assessment really helps facilitate a safe discharge.’

For Hannah Johnston, a physiotherapist who oversees the program in her aged care health reform role, the need for the FDF program was urgent. 

‘The Northern Territory has the most rapidly ageing population in Australia and all of our acute tertiary hospitals are under extreme bed pressure, with very busy emergency departments,’ Hannah says. 

‘We also knew we had a lot of potentially avoidable admissions of older people, where they experience poorer outcomes than if they were able to be discharged home.’

The FDF program was inspired by successful overseas models, mostly in the UK. 

A consultant geriatrician who had previously worked in the UK’s National Health Service was instrumental in establishing the FDF team and brought experience from well-established frailty programs. 

At its core, the FDF program ensures that decision-makers are at the front door of the hospital. 

Frail older people who arrive at the emergency department are screened using the Clinical Frailty Scale and if they meet the inclusion criteria, they receive a comprehensive geriatric assessment in the emergency department.

Daily huddles in a dedicated space in the ED ensure that the team can prioritise patients and plan their care together. 

‘It’s so rare for somebody to be able to come into ED and have all the services on their doorstep,’ Alex says. 

‘Providing that comprehensive assessment all in one go—as a one-stop shop essentially—has been very successful.’

But the FDF team doesn’t work in isolation. 

Once patients are assessed and stabilised, they are often referred directly to the community frailty service at the hospital for follow-up and ongoing support.

That’s where physiotherapist David Foster, the team leader of the community frailty service, comes in. 

David Foster.

Patients discharged from the ED are referred into the hands of David’s team, which comprises a physiotherapist, an occupational therapist and a speech pathologist. Recruitment is underway for a dietitian, an allied health assistant and administrative support.

The team literally takes the program on the road and out into Darwin’s suburbs.

‘We’ll go out to the patient’s home, generally two of us at a time, and meet them in their own environment. 

'That gives us a much more specific idea of what they need,’ David says. 

'We do a holistic review and keep them at home, well supported.’

Assessments cover everything from mobility and balance to home safety and equipment needs. Carer education is also a big part of the service. 

‘A lot of fear avoidance behaviours creep in,’ David says. 

‘Carers sometimes want people to stop doing things because of the risk but it’s important for quality of life that patients keep doing the things they want to do—safely.’

Home and community exercise programs also play a critical role in preventing physical deconditioning and reducing the risk of falls, while simultaneously improving strength, balance, independence and the overall functional ability to remain at home.

The FDF program is supported through the Australian Government’s Strengthening Medicare—Supporting Older Australians funding. 

Hannah says the national funding is designed to support initiatives that keep older people out of hospital and to support people to age at home. 

In the Northern Territory, the FDF program is funded until 30 June 2028, granting certainty that allows for ongoing recruitment, service development and robust evaluation. 

The ongoing funding comes off the back of a successful 12-month pilot of the program.

The FDF program also works to address the needs of Aboriginal and Torres Strait Islander patients, who are often more vulnerable to frailty at a younger age. 

Hannah Johnston.

In the ED, Aboriginal and Torres Strait Islander patients aged over 50 are screened using the Clinical Frailty Scale, compared with the age 65 threshold for non-Indigenous patients. 

In the community, the FDF model is equally important for supporting Aboriginal and Torres Strait Islander people to remain at home and, wherever possible, to age on Country.

Hannah says the FDF program is working in parallel with other Territory initiatives that support older people to age in place. 

‘There are physios working with remote communities in the Top End to explore healthy ageing and how to support people to age on Country.’

Another strength of the FDF model lies in its integration of hospital and community care, Alex says. 

‘You can’t have an ED service without the community aspects as well. It’s all one team. 

'We can only do so much assessment in ED but having the safety net of a comprehensive community follow-up makes all the difference.’ 

David agrees, saying, ‘We integrate—you’ve got the FDF in the hospital, you’ve got us in the community and then you’ve got the long-term community services or exercise programs. It’s all about continuity.’

Although still in its early stages, the FDF program has already shown promise. 

Hannah says more than 400 patients (at the time of publication) have been seen since the pilot began a year ago, resulting in fewer admissions and more people supported at home.

For Alex, the daily wins are clear: ‘Any time we’re able to promote a safe discharge that would otherwise have led to a hospital admission is a success.’

All those at the forefront of the FDF program, and those with oversight across it, see enormous potential in further development of the program. 

Future plans include potentially expanding into paramedic services, introducing falls and balance group classes in Darwin, and strengthening links with GPs and aged care providers.

David believes the model is critical, not just for patients but for the health system as a whole. 

‘Hospitals are full. Nursing homes in Darwin are full. 

'If we can support people at home for longer, that’s a fantastic win—primarily for the patient but also for the health service.’ 

For Alex, the program demonstrates how integrated, multidisciplinary care can make a real difference in the lives of older Australians. 

‘What our team is very good at—what physio is very good at—is seeing the bigger picture. 

'Instead of just looking at falls and mobility, we’re looking at appetite, sleep and social and emotional wellbeing. 

'That’s the joy of having an integrated team working so closely together,’ she says.

David says supporting people where they want to be is what drives the FDF program. 

‘People don’t generally want to be in hospital. They don’t want to be in a nursing home. They want to stay at home as long as possible,’ he says.