Description:
Facilitated meetings were funded and lead to the establishment of a monthly clinic for people living with frailty. A consultant physician works alongside a social care lead in a GP surgery with access to the GP, a mental health care lead, and the community team. It is an integration of health and social care. Patients are identified by all members of the community team and referred via the GP. A combination of mobility problems, carer needs and often memory problems was the best indicator of frailty. Patients had an holistic assessment over one hour then half an hour social care advice. Carers and relatives were involved at all stages and social care input was given for the home environment, benefits and advanced care plans and respite arrangements. Initially set up with goodwill this became a service reconfiguration with no additional cost the NHS.
Outcome:
Over the last two years approximately one hundred patients and carers (usually also patients) have been supported. Involvement of carers is key as is the use of primary healthcare records with appropriate templates to transfer the records of each involvement organisation. Evaluation has shown reduced GP usage and GP cost savings. Qualitative research has shown positive feedback from all patients, carers and staff with reports of improved quality of life and admissions prevented. The next stage step is a Hampshire wide approach catering for all aspects of frailty from prevention to crisis and end of life care.
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