Information for health and social care professionals to inform MDT referral criteria and expectations of attendees.

Purpose of Frailty MDT meetings

The Frailty MDT Coordinator service brings together the expertise and skills of different professionals to assess, plan and manage care jointly at PCN level. Through accessing a range of health, social and other community services, PCN MDTs focus on keeping people well and independent, delivering the right care at home to prevent unnecessary hospital admissions.

The MDT coordinators are responsible for all administration and organisation of the west Kent PCN MDT Frailty Meetings. The service will take referrals from all members of the multidisciplinary team including GP’s, complex care nurses, community nursing, social services, dementia nurses, specialist nurses/physios, therapy leads, link workers within care navigation and the voluntary sector.

Referral criteria and guidance on how to refer

You do not need patient consent to refer, however patients should be informed by the referrer that referral has been made to MDT for discussion; before submission. If referral has been made in the best interests of the patient; please identify this in your referral.

Referrals must be uploaded to the patients’ KMCR record using the SBAR format. An email should be sent to the MDT Co-Ordinators’ email address (kentchft.mdtcoordinator@nhs.net) to inform that a referral has been made on KMCR.

For voluntary/external services that do not have access to KMCR; referral should be made using SBAR document and emailed to MDT Co-Ordinator address.

Please note: All Primary Care, KCC and KCHFT staff should have access to KMCR. If this is an issue for you or your team, please inform us or your IT department to resolve this issue.

We kindly ask that you review the patient referral criteria before submitting a new referral. Referrals for MDT discussion should:

• Clearly state the reason for referral; using the below as reference.

Include relevant clinical background and interventions already undertaken

• Identify the goals and wishes for MDT discussion
• Information provided on patient should be up to date and reflect concerns identified within the last three months
• Clearly state if patient has been identified via John Hopkins Risk Stratification tool (relevant for Primary Care staff)

If referral does not meet criteria or provide enough information for discussion; it may be rejected.

Patients who are suitable for discussion:

• Registered with west Kent GP
• Patients aged 65 years and over
• Patients with a clinical frailty score of five and over for proactive intervention.

How can I identify frail patients for referral?

• Identified through John Hopkins Risk Stratification tool
• Post-hospital discharge patients
• Patients with multiple long-term conditions
• Patients with onset dementia
• Patients who have frequent falls and/or are incontinent
• Patients with a sudden change of mobility/severe mobility issues
• Patients with a susceptibility to medication side effects.

Referral exclusion criteria

• Under the age of 65 years
• Primary concern relating to single condition where single specialist pathway would be more appropriate (for example, pain clinic, mental health, psychiatry, respiratory, cardiology)
• Any acute condition – please refer to reactive services for more urgent intervention
• Primary concern relating to patients actively on end of life or on palliative care pathway.

If patient does not meet the above criteria, but you feel they would still benefit from clinically frail MDT discussion; please request for referral to be discussed with GP Frailty Lead.

Our Frailty MDT Co-Ordinator’s

Each PCN will have a designated MDT Co-Ordinator that will organise and co-ordinate the set-up of Frailty MDT meetings and monitor actions/outcomes.

The designated PCN MDT Co-Ordinator plays a key role in ensuring the smooth operation of the Frailty Multi-Disciplinary Team (MDT) process. Their responsibilities include:

• Referral Management: Receive and triage all referrals to the Frailty MDT to ensure appropriate inclusion.
• Meeting Preparation: Compile and circulate the patient discussion list in advance of each MDT meeting, notifying all relevant attendees.
• Meeting Facilitation: Chair the Frailty MDT meeting and accurately record minutes and agreed actions.
• Documentation: Upload the meeting minutes and agreed actions to the Kent and Medway Care Record (KMCR) in a timely manner.
• Follow-Up and Referrals: Initiate any onward referrals as agreed during the MDT meeting.
• Action Tracking: Monitor progress on agreed actions, liaising with responsible individuals to ensure outcomes are recorded on KMCR.

What happens next?

Post-frailty MDT process and responsibilities

Following the Frailty MDT discussion, the MDT Coordinators will:

• Finalise and upload all meeting minutes and agreed actions to KMCR.
  • If you do not have access to KMCR and require minutes, please request these to be sent to you, at the Frailty MDT meeting
• Initiate any onward referrals as agreed during the MDT meeting
  • Any referral that follows the MDT would be covered on the legal basis that as long as patient is fully informed, implied consent is sufficient for us to proceed.
• Monitor progress on agreed actions, liaising with responsible individuals to ensure outcomes are recorded on KMCR

It is the responsibility of the referrer to feedback to patient following the MDT discussion; to advise of outcomes.

Patient caseload management

• Patients will remain on an internal MDT caseload until all actions are completed.
• If actions remain outstanding beyond the expected timeframe, this will be escalated to the relevant service lead or manager for review.
• If no response is received from the action owner after follow-up attempts, the patient may be discharged from the MDT caseload.

Due to the high volume of patients discussed, MDT Coordinators are unable to hold caseloads indefinitely. We appreciate your cooperation in ensuring that patient outcomes are actioned and recorded promptly and accurately.

Referral process flowchart

• Inform patient that they will be referred to Complex Frailty MDT
• Are you employed by KCC, KCHFT or Primary Care?
  • Yes
    • Input referral onto KMCR using SBAR format (ensure patient referral criteria has been read and applied to avoid rejection)
    • Email patient name and NHS number to kentchft.mdtcoordinator@nhs.net to inform team referral has been uploaded to KMCR (ensure this has been sent in by your PCN deadline to avoid rejection or delay).
    • If your referral has been accepted/rejected, the MDT Co-Ordinator team will inform you via email.
  • No
    • Email your referral to kentchft.mdtcoordinator@nhs.net using SBAR format with patient name and NHS number (ensure patient referral criteria has been read and applied to avoid rejection).
    • If you referral has been accepted/rejected, the MDT Co-Ordinator team will inform you via email (ensure this has been sent in by your PCN deadline to avoid rejection or delay)..
• If accepted, patient will be added for discussion at next MDT meeting.