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What is Frailty?
Frailty is a condition that describes a decline in a person’s state of health related to the ageing process. While many older people are living well, an older person living with frailty may lack the reserves to cope with even minor changes in their physical or mental health and wellbeing. A person’s level of frailty can fluctuate, and people do not identify themselves as frail. Small events such as a change in environment or an infection may present a challenge to the frail older people from which they may or may not recover to their previous function. This group of patients are at high risk of admission to hospital, so we are likely to see them on any of our adult wards.
The frailty team will enable you to discuss patients’ health and social care situation with family and friends from the point of arrival at hospital.
We act as advocates for our patients and make sure their wishes are heard and a plan is made for their care. Our aim is to prevent unnecessary or prolonged stays in hospital which can be an unfamiliar and uncertain place to be for our patients.
We make a plan for them to receive the appropriate level of care in a place of your choice. Older people living with frailty are often put at increased risk of ill health being in hospital rather than their own home.
The frailty practitioners are all experienced healthcare professionals with an interest in the care of the older person living with frailty.
We as a team come from a variety of professions such as:
- Physiotherapist
- Occupational Therapist
- Nurses
- Mental Health Nurses
- Pharmacist
They have experience of working in both hospital and community settings and of undertaking holistic assessments. As a team we currently process specialist knowledge on dementia, older person’s mental health, heart failure, stroke, falls, polypharmacy and palliative care.
Our patients are discussed within a MDT and we have access to Geriatrician support should we need it.
- Comprehensive geriatric assessment
- Quality of life
- Trageted care
- Medication reviews
- Early MDT care planning
- Admission avoidance
- Signposting
- Advocating
- support medical team with clinical decision making.
- Respect/advance care planning
- Linking with community & inpatient services.
- Communication between families & patients
Please search on green brain for the following courses:
- Frailty - Tier 1 - For Non-Clinical Staff: This course supports the wider knowledge and understanding of frailty in the public domain. It details the concept of frailty, how it is assessed and managed. The training will help support and empower people to access frailty assessment and assistance early.
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Frailty - Tier 2A (For Bands 2-4): This course is focused on health and social care workforce who may come across frailty but do not routinely work in acute frailty services but do work in multiple other areas.
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Frailty - Tier 2A (For Bands 5+): This course is focused on health and social care workforce who may come across frailty but do not routinely work in acute frailty services but do work in multiple other areas.
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Frailty - Tier 2B: This course is focused on health and social care workforce who work in acute emergency services, acute frailty services or specialist frailty units.
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The primary purpose of the service is to support and enable patients who have 2 or more of the frailty syndromes listed across and score 6 or higher on the Rockwood score to live well with frailty.
We work in partnership with our Emergency department colleagues, therapy services, the medical team and community services.
We see patients in the Emergency department and aim to start a comprehensive geriatric assessment (CGA) on an identified frail patient within 60 minutes of arrival to hospital.
We also see patients on all wards that have been admitted over the night, that are on the take list. Also any patients that have been refered to us via epurple or telephone call.
Patients age 75 or over , who have two or more of these 5 frailty syndromes:
- Falls - "legs gave way" , "found lying on floor"
- Delirium - acute confusion , worsening of pre-exisiting cofusion.
- Immobility - reduced mobility, struggling to complete avtivities of daily living
- Polypharmacy - increased likelihood of adverse reaction to medication or decrease medication compliance.
- Incontinence - new or worsening
To refer to our team. Please make sure that you have identified an appropriate patient. As listed Above, we accept patients with 2 or more Frailty Syndromes & scores a rockwood 6 or higher.
You can refer to us via Epurple Referral or contacting our team.
Frailty epurple Referring service: "HHFT: Med:Frailty (Frailty Review Data)"
Frailty Team Contact details:
Ext : 49804 (BNH)
Ext : 24252 (RHCH) , Bleep: 3171
The importance of identifying Frailty.
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Older persons assessment Clinic
Wht are we?
The older person persons assesmnet clinic is a Multidisciplinary clinic providing comprehensive assessment for Older People at risk of deterioration in the community and unplanned admission to hospital supporting older people and their significant carer to maintain the best quality of life for as long as possible.
It is designed to be a One stop shop, for all falls and Frailty Assessment. Primary clinic appointments may be delivered by a consultant geriatrician, consultant nurse, frailty ACP, specialist pharmacist or registrar depending on the triaging of the referral.
Interventions and Assessments will follow the Comprehensive Geriatric process.
- Age >75 (or > 65 with multiple co-morbidities)
- Clinical frailty scale score of >4 (vulnerable)
- Multiple co-morbidities/non-specific symptoms (2+) that would benefit from a holistic approach that may require diagnostics & Geriatrician review.
- Acute Functional decline
- Unexplained recurrent falls and collapse
- Problematic polypharmacy and/or decreased medication compliance.
- Polypharmacy
- E-Purple for In-Patients.
- Priority - Outpatients
- Target serives (RHCH referal) - RHCH:MED:Elderly:CARE:RAU (Med Elderly Care)
- Target serives (BNH referal) - BNHH:Med:Elderly:Care
- Please contact the Specialty Co-Ordniator on each site if you would like to dicuss. :
- (RHCH) Contacting the Specialty Co-Ordniator via ext: 28368
- (BNH) Contacting the Specialty Co-ordinator via ext: 45358
- Clinic letters from services which don’t have access to e-purple referral process.
- ERS for Community patients
