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The community frailty assessment service launched in April 2021 with the aim to improve the care and treatment of frail, older people in the community.
The team is made up of GPs with a special interest in frailty, a physiotherapist, occupational therapist and a frailty assistant practitioner.
There is weekly consultant geriatrician support provided from the East and North Hertfordshire NHS Trust who provides specialist support to the team.
The aim of this service is to:
- Provide specialist holistic medical and functional reviews in to improve or maintain quality of life.
- Minimise crisis situations and requirements for emergency interventions or hospital admissions.
- Increase ownership and control over the individual’s health through personalised care planning and setting goals with patients.
- Improve access to existing services through a coordinated MDT approach.
The overall goal is to empower patients utilising the frailty service to:- Understand their medical conditions and any medications,
- Develop an awareness of their abilities and potential limitations,
- Increase their awareness of how they can improve their own well-being by accessing relevant voluntary community services, such as exercise classes and groups.
- Improve self-management skills which results in individuals being able to improve or maintain their quality of life for longer.
- How the service is provided
- Who is eligible for the service
- What will happen at your appointment
- Useful information
- Making a referral
- Patient experience
How the service is provided
A virtual (video) appointment will be arranged with the frailty GP during one of the weekly clinics.
Clinics take place on:
- Monday, 10am-1pm
- Tuesday, 10am-1pm
- Thursday, 10am-1pm
Following this initial appointment, the frailty GP may feel that a physiotherapy or occupational therapy assessment would be beneficial, depending on the needs of the patient.
Physiotherapy and occupational therapy interventions are delivered within the patient’s own home, and therefore this will be arranged directly with the individual.
The frailty assistant practitioner may visit patients to conduct blood tests, ECGs and carry out therapy related interventions after the therapists have assessed the patient.
A fortnightly partnership multidisciplinary team meeting has been set up in order to provide a collaborative approach to a patients care.
At this meeting there is representation from:
- Hertfordshire Partnership Foundation Trust
- Hertfordshire adult care services
- Hertfordshire adult disability services
- Herts Help
- Garden House Hospice
- Pharmacy
- Dietetics and nutrition team
- Princess Alexander acute frailty service
Patients are discussed with the team in order to navigate onto the most appropriate services when needed and ensure a smooth transition between these.
Who is eligible for the service
Individuals who:
- are registered with an East or North Hertfordshire GP
- Rockwood score of 6 (see Making a Referral section below for details of this score)
- Adults with a learning disability and a moderate frailty score.
- Patients who are safe and medically stable to remain in their home environment.
What will happen at your appointment
On receiving a referral to the service, the team will conduct a triage – which involves reviewing the individual’s medical notes, any recent investigations and also previous interventions from Hertfordshire Community NHS Trust services.
After the triage stage the administration team will contact the patient to confirm the correct mobile telephone number and organise the virtual appointment. At this point the patient is asked if they are able to manage the virtual appointment (via Attend Anywhere).
- If the patient can manage this independently then an appointment will be made with the frailty GP.
- If in the case whereby the patient cannot manage the virtual appointment for whatever reason the frailty assistant practitioner can be present with the patient during the frailty GP consultation. This will be organised and booked via the administration team.
A letter will be sent to the patient with the details of the appointment and a questionnaire. It is advisable for the for the patient to look over and complete the questionnaire prior to the clinic appointment as this will help to get the most out of the allocated time.
The link provided will give details regarding how to log on to the Attend Anywhere waiting room. At the allotted appointment time the frailty GP will start the consultation.
Each patient will have a comprehensive geriatric assessment completed with the frailty GP and this will be saved onto the clinical records system (SystmOne). Depending on the needs of the patient the frailty GP may feel that a physiotherapy or occupational therapy assessment is required and will discuss this with the therapists in the team.
The physiotherapist/occupational therapist will arrange to visit the patient in their own home to conduct a specialist holistic assessment which may include:
- Muscle strength, balance and mobility
- Falls risk/s
- Functional ability
- Cognitive function
Any therapy treatment plans and ongoing referrals suggested will be discussed with the patient, along with goals that they wish to achieve during the sessions.
The frailty assistant practitioner may visit patients after their initial appointment to conduct:
- blood collection for further investigations
- to conduct an ECG (if indicated by the frailty GP)
- deliver a home exercise plan and mobility sessions
- conduct functional activities to improve confidence
Useful information
Websites
The British Geriatrics Society offers specialist expertise in the wide range of healthcare needs of older people. They have published a multitude of resources for primary care practitioners:
https://www.bgs.org.uk/resources/resource-series/comprehensive-geriatric-assessment-toolkit-for-primary-care-practitioners
AGILE is a Professional Network of the Chartered Society of Physiotherapy (CSP) and is for therapists working with older people. There is a vast amount of research articles on the CSP web site relating to the benefits of physiotherapy for those living with Frailty:
https://www.csp.org.uk/frontline/article/strength-exercises-protein-best-delaying-frailty
The British Association of Occupational Therapists is the professional body representing occupational therapy staff across the UK, The Royal College of Occupational Therapists (RCOT) is a registered charity and wholly owned subsidiary of the Association, which acts on behalf of all members of the Association and sets the educational and professional standards for the members.
https://www.rcot.co.uk/occupation-matters
https://www.rcot.co.uk/occupational-therapy-primary-care
Hertfordshire Independent Living service ‘provide a range of services to help older and vulnerable people stay happy, healthy, and independent’, including meals on wheels, nutritional information, advice for some medical conditions and also Active Ageing exercise classes.
https://hertsindependentliving.org/
https://hertsindependentliving.org/active-ageing/
Herts Help is a network of community organisations working together providing information and guidance to individuals.
https://www.hertshelp.net/hertshelp.aspx
Live Longer Better in Hertfordshire is an initiative being led by Herts Sports and Physical Activity partnership to change the culture of ageing, replacing the concept of care with the concept of enabling.
https://www.livelongerbetterinherts.co.uk/
Centre for Ageing Better is a charitable foundation, funded by the National Lottery Community Fund, and part of the government’s What Works Network.
https://www.ageing-better.org.uk/
Making a referral
For patients whose GP is in East and North Hertfordshire please send the referral to
hct.communityfrailtyservice@nhs.net.
Referrals can be discussed by accessing the team via the East and North referral Hub on 0300 123 7571.
GPs can refer using the form on ARDENS.
The referral should include the following details: 
- Rockwood clinical frailty score (see table oppsite)
- Past medical history
- Any recent attendances at A&E
- Reason for referral
- Blood results (within the last 3 months)
- Result of result ECG (if clinically indicated)
All referrals are triaged daily by the frailty team.
If a patient is deemed inappropriate for the community frailty assessment service then this will be redirected onto the relevant service, and the referrer will be informed.
Patient experience
If you would like to share your story, please contact the Patient Experience team on 01707 388036 or email hct.patientexperienceteam@nhs.net
The community frailty assessment service values your opinion and would welcome anonymous feedback via a short survey. Your feedback helps us to improve our service.
If you would prefer to access the survey in paper format, please contact the team on 0300 123 7571 and we will post a copy to you with a postage-paid envelope for you to return it to us.
