Frailty practitioner service

It is now recognised that ‘frailty’ is a condition that describes a decline in a person’s state of health that is related to the ageing process.

While many older people are living well, the older person living with frailty may lack the reserves to cope with minor changes in their physical or mental health and wellbeing. A person’s level of frailty can fluctuate and people often do not identify themselves as frail. Small events such as a change in environment or an infection may present as a challenge to the frail elderly from which they may or may not recover to their previous function.

What does the Frailty Practitioner Service do?

Our service takes referrals from GP’s, other community services and the local acute hospitals. Our service aims to improve the lives of older people who are 75 years and over and who have either been admitted to hospital three times or more in the past year or have recently been discharged from hospital.

You will be visited in your own home and a comprehensive clinical assessment undertaken which includes memory screening, a medications review and a discussion about wishes and preferences for your future care. The assessment is discussed with a Consultant Geriatrician and information is shared with the GP and other relevant professionals including the ambulance service with the individuals consent. A follow up meeting is arranged to ensure that the plan is helping to meet your desired outcomes.

The service is a short term service and you can expect between one and six visits over a period of 4 to 6 weeks depending on your need. As part of the agreed plan and with a view to provide ongoing support we may refer you on to other professionals who would be involved with you over a longer period.

Who are the frailty practitioners?

The Frailty Practitioners are all experienced healthcare professionals with an interest in the care of the older person living with frailty. They have experience of working in both hospital and community settings and of undertaking holistic assessments. Every patient is discussed with a Consultant Geriatrician to support clinical practice and decision making.

What are the benefits of the service?

The Frailty Practitioner team will enable you to discuss your health and social situation, with friends or family present, if you wish, to ensure that your wishes are heard and a plan is made for your care. If a friend or family member supports your care we will offer a Care for the Carers referral for their assessment. The aim is to prevent unnecessary or prolonged stays in hospital which can be an unfamiliar and uncertain place to be. We plan for you to receive the appropriate level of care in the 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.

Contact details

Tel: 0300 131 4437