Description:
We are a relatively new team that has been set up to manage the expanding Frailty caseload. The practice has a population of 43,000 patients. At the moment approximately 1500 patients are managed. This includes severe, moderate and mild Frailty, and also encompasses vulnerable groups such as learning disabilities and mental health. We have a Care Coordinator who manages the Frailty Line- a direct phone number set up to allow patients to contact the team/practice directly. The team carry out proactive holistic 'top to toe' assessments and conduct follow up reviews ongoing to ensure patients feel supported.
Outcome:
The main aim of the service to stabilise patients and encourage self-management, but also to prevent hospital admissions by advance care planning.
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