Frailty Service

Our Frailty Services generally supports people over the age of 65, to live well at home.  This is a new service and we hope to:

• Provide holistic assessments in patients own home, identifying barriers they are currently facing in terms of activities of daily living, and providing intervention where needed to enable individuals to remain at home as independent as possible.
• Reduce crisis GP attendances / admissions.
• Refer patients onto relevant community services as and when needed. For example, community rehab team, falls clinic, memory clinic, wheelchair services.
• Provide continuity of care and building rapport with our patients to avoid presenting in crisis states and avoid unnecessary admissions.
• We aim to complete a personalised care plan with each individual who is on the frailty case load. This includes having conversations with patients about what is meaningful to them in terms of their care and management. It also touches upon conversations about future planning, to help to prompt thoughs about future wishes for care.