Description:
What matters most to the patient
Devising individualized, patient led management plans addressing the management health care conditions through social prescribing to achieve their stated goal.
Caseload finding through GP note finding screening those with moderate frailty score, long term conditions (HF, high BP, diabetes, COPD, CKD) codes. 39 patients identified, nursing homes and severe cognitive impairment not approached, 3 declined, 10 patients visited.
Outcome:
To delay a decline in frailty, hospital admission avoidance, reduce patient GP + OOH contacts. Details and case studies to follow.
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