The Trust has started a new service aimed at supporting frail people to live independent and healthy lives out of hospital.
The new team of eight Frailty Practitioners will coordinate the care of frail people so they can be supported to live independently at home. Using the advanced clinical skills of the team, a comprehensive geriatric assessment will be undertaken to assess a frail person’s needs and a plan of care to support them will be created. This will, in some instances, also include planning for future care needs.
As the Frailty team develops its specialist knowledge and links to resources available in the community, it will utilise these within care plans. This will help patients to remain within community settings, or be discharged from hospital appropriately to live independently, for as long as possible, without the need for being readmitted to hospital. The medical side of the work of the team will be overseen by Dr Elena Mucci who is a Consultant Geriatrician at the Trust.
Sue Lyne, Nurse Consultant for Frailty and Older People/Frailty Practitioner said: “Our new service will help support frail older people live independently at home, which is something many want to carry on doing. Our service is very much wrapped around the needs of the frail person and the team will work closely with the existing community and hospital workforce. We hope to not only reduce the number of frail elderly people who are in hospital whose care could be done more effectively in the community, but try and avoid admission to hospital altogether with more robust preventative services in place.”