Who are we? 

We are a multidisciplinary team with expertise in supporting people living with frailty, in their own homes. Our Frailty Practitioners lead the day-to-day care, coordinating advice and visits from our Occupational Therapists, Physiotherapists, Pharmacists and Healthcare Assistants as needed. Our Advanced Clinical Practitioners, GPs with a specialist interest in Geriatrics and Consultant Community Geriatricians are involved in every person’s care too.

What do we do? 

We respond to an imminent crisis at home (or shorten a hospital stay) with the aim of reducing potentially unnecessary time spent in hospital. We do this through multidisciplinary, holistic assessment (comprehensive geriatric assessment). This often involves talking to people about issues broader than their presenting complaint. Clinical observations and monitoring, blood tests, in-depth medication review and rationalisation, new prescriptions, request imaging, falls assessments, review of long-term conditions are commonly performed. Treatment escalation discussions are a key part of the care we provide. We see people where they live, be that a private home or a care home. People are usually under our care for 1-2 weeks. We don’t provide or set up personal care, but often work alongside those with carers, or other teams involved in their care.

Who do we see? 

People living with frailty (Clinical Frailty Score – CFS ≥5) at risk of, or stepping down from, a hospital admission. We’re not a same-day emergency service but respond within 72 hours. The people we see will often have problems with falling over, confusion, multiple symptoms, multiple conditions, polypharmacy or incontinence. Those with unstable long-term conditions (heart failure or COPD for example) and or multiple admissions/attendances may also benefit from our holistic assessment, to try and get to the root causes and improve their health.

We see people who live in Plymouth, South Hams and West Devon. The service doesn’t extend into Cornwall.

Who can’t we help? 

Those who:

• Aren’t frail (CFS < 5)
• Decline referral (we see some people in their best interests if unable to consent)
• Are acutely unwell or have emergency/same-day needs
• Have 24-hour care needs/aren’t safe to be left at home between carer visits
• Are likely to need more than two weeks of assessment and intervention
• Need only the response of one professional, not a team approach

 

Give us a call if you think we can support your patient

We aim to include, rather than exclude so give us a call on 01752 437777.