LAUSR

Introduction: Frailty is a dynamic state of increased risk of disability and worse health outcomes in older adults. Frailty represents a critical phase of declining capacity associated with aging, which might range from an early decline to advanced stages. In this line, the WHO promoted a positive view of aging as a life-course process of developing and maintaining functional ability. Practice change: A real world program for integrated geriatric and primary care for frail older adults in a primary care area of Barcelona, has been implemented. It has been built on the reorganization of existing resources, generating a change in the usual practice. A geriatric team (geriatrician + physical therapist) attend 1day/week to the primary care center, in order to assess frail older adults referred by the primary care team (Gerontopole FST). According to the deficits, a tailored and coordinated multidisciplinary treatment plan is proposed: a)health education; b)pharmacological optimization, c)multi-modal physical activity (10 sessions, 1 hour/week). The geriatrician performs a 3 months follow-up. In agreement with the continuity of care approach, primary care teams take responsibility for the rest of the follow-up, promoting the achievement of shared goals and fosters empowerment during the follow-up, leaving the geriatrician's intervention on demand. Aim and theory of change: To improve the care of frail older adults in the community, and evaluate if the development of a real-life multicomponent tailored program has an impact on the physical performance (frailty indicator) at the end of the program. Targeted population and stakeholders:  The screening assessment is directed to older adults in a primary care area of Barcelona, +80 years, without physical disability and/or acute clinical disease and present ³1 sign of frailty. Timeline: The program and intervention started in 2016 and is still on-going. Highlights: +AGIL Barcelona represents a good example of collaboration and coordination between primary and geriatric care, is innovative, because it implements, in the real world, a new specialized and multidimensional model of care for frail older adults in the community, through an intervention individually modulated according to specific needs. Comments on sustainability and transferability: The sustainability is guaranteed as it does not rely on extra funding but builds on the reorganization of existing resources. Experience can be transferred and replicated in other primary care centers in other regions, adapting the interventions to the population and environment characteristics. Conclusions: According to our results, a multidisciplinary integrated and comprehensive geriatric intervention in frail older community-dwellers, using existing resources, may improve physical function and almost reverse frailty at 3 months, according to reference value. Further studies are needed to address the long-term impact and scalability of this implementation project. Discussions: Different programs merging the primary care and geriatric expertises in coordinated pathways have been described. However, besides the experience of Gerontopole in Toulouse, these experiences were conducted under rigidly controlled experimental conditions and schemes, making difficult the implementation and sustainability of the same activities in real life Lessons learned: Flexibility of inclusions criteria and the multidisciplinary work  are the key components of the program.