20 April 2023

How the community frailty team are helping to break the cycle of hospital admissions

The frailty practitioner team

Treating patients so they don’t need to come into hospital is just as important as the care they receive while in hospital. The community frailty team, who cover the area from Seaford over to Rye, specialise in treating people over the age of 75 who are living with frailty.

Frailty is a medical condition describing a decrease in physiological reserves which leaves a patient less likely to respond or recover from ordinary events such as a minor illness or even the stress of moving house.

Mark Summerfield is a Frailty Practitioner based in the community. “The work we do is to intervene for patients who are in a cycle of hospital admissions and re-evaluate their care by visiting them in their home and carrying out an assessment, face-to-face, often with family present who can help provide useful information,” says Mark. “Our intervention can help to break the cycle of hospital admissions, declines in health and reliance on health services. We are looking at what the best outcome for the patient is, but also what their own goals are. Mainly that is to be able to live as independently as they can for as long as possible.

“Frail patients are not generally ill,” continues Mark, “so we are not trying to fix anything, rather we are adjusting what is already there so that it works better for them and gives control back to them and their family.  A good way to do this can be by helping them step down the medical treatment they are currently on.

“After we’ve assessed them we work to co-ordinate multiple streams of care and preventative care, to help prevent unnecessary procedures and time spent in hospital. We can discuss and review their pathway with their consultant and with the pharmacy team to optimise care, while still being patient-centric and working on their goals.”

The team itself has just celebrated its seventh anniversary. It was set up by Dr Mucci, Frailty Consultant, and Sue Lyne, Nurse Consultant, and has gone on to become well-known across the country with team members regularly presenting at conferences on developments in the service. The team are currently looking at how they can link up with the virtual wards team to improve care for people in their homes.

The feedback the team has received has been extremely positive. From the last audit it was found that 6,400 bed days have been saved between 2017-2019 and over 500 admissions. Mark adds, “It is so rewarding as we can see the impact that we are having on people. What we are doing is working and is really appreciated by our patients. They can maintain their dignity and autonomy as older people, which is really what all of us want to be able to do as we age.”