Frailty Team

Who we are

The team includes:

• Doctors (including consultant geriatricians)
• Advanced clinical practitioners and trainee advanced clinical practitioners from a variety of healthcare backgrounds. You may be assessed by a trainee advanced clinical practitioner. These are experienced qualified healthcare professionals who are completing further training.
• Complex care nurses
• Administrators

What we do

It is our job to recognise people who may be becoming frailer, help them to manage this as far as possible and help those people and their families/carers to plan for the future. This may include discussions around how they want future episodes of illness and decline to be managed and how they would like their situation to be towards the end of their life.

Frailty is a term that describes a gradual decline in a person’s function. Someone who is frail may find it increasingly difficult to manage the everyday activities that they are used to doing independently. They may have multiple medical conditions and may find they have had to go into hospital more often recently. Frailty is defined as a “lack of resource” to fight new problems, for example, infections or falls or change in social environment.

What will happen during a home visit?

A doctor or advanced clinical practitioner will visit to discuss how you are managing. They will complete a comprehensive assessment, which involves assessing a variety of different issues that can affect frail or older people, including memory screening and a medication review. The assessment may include a physical examination also.

We will ask you “what is important to you” and try to focus our responses to this. We will also talk about your views about medical interventions and what you would wish towards the end of your life.

The team works closely with the acute hospitals, local GPs and other health and social care teams. We may share information from our assessments with these teams but only where this is necessary to provide the best support to you and your family/carers.