Further Information
This multidisciplinary team includes a Paramedic, Frailty Matrons, Clinical Coordinators, and a Clinical Pharmacist, supported by various other services and organizations. Our goal is to enhance the quality of life for these patients, helping them maintain independence and reducing the likelihood of unplanned hospital admissions.
Services Provided by the Integrated Frailty Team
The team offers comprehensive assessments, guidance, and support to individuals either living independently at home or in care facilities. We address needs arising from frailty—a medical condition characterized by reduced resilience to health changes, potentially compromising independence. Our services extend to evaluating home environments, discussing personal preferences, and planning future care needs. By coordinating closely with health, social care, and voluntary sectors, we facilitate access to a broad spectrum of support options.
Role of Advanced Practitioners
Our Advanced Practitioners collaborate with GPs and medical staff to conduct thorough physical assessments, diagnose health issues, and prescribe medications as needed. They play a crucial role in the regular monitoring and management of care in local care homes within the Primary Care Network.
What Does the Integrated Frailty Service Do?
- Conducts regular ward rounds in all network care homes.
- Assesses personal needs to support healthy living at home.
- Educates patients and their carers about managing specific health conditions.
- Identifies when additional home services might be necessary.
- Develops, updates, and reviews personalized care plans in collaboration with the patient, their family, carers, and healthcare professionals.
- Ensures communication and understanding of patient needs among all health and social care providers.
- Facilitates referrals to beneficial services such as social services, specialist healthcare, and voluntary agencies.
Understanding Care Plans
Care Plans are collaborative, personalized documents created by the Integrated Frailty Nurse and the patient, with possible input from family members or carers. These plans provide essential health information to help healthcare professionals understand and respect the patient’s health needs and preferences.