Objectives

• To Encourage and supported patients to optimise their health and wellbeing, through self-management.
• To Reduce A&E attendances and unplanned admissions in frail patient population.
• Treat and care for patients in a safe, effective and appropriate way.
• To Provide enhanced integrated pro-active care.
• To Provide patients with the right support at the right time before they reach crisis – thus improving their health outcomes and the impact on the wider care system.

Achievements

• High patient satisfaction – positive feedback from patients due to seeing 4 different clinicians and receiving personalized care
• Utilization of follow-up appointments have increased
• Developed a skilled and stable MDT
• Increased patient independence and participation in activities of daily living
• Reducing polypharmacy
• Preventing falls
• Proactive Care service – Prevention is better than cure!!

Benefits of the Service

• Comprehensive Assessment: Thorough evaluation of physical, psychological, and social factors.
• Personalised Care Plans: Tailored care plans for each patient’s specific needs.
• Multidisciplinary Team: Integrated care from a team of healthcare professionals.
• Hospitalisation Prevention: Reduces risk of acute health crises and hospital stays.
• Enhanced Mobility: Programs to improve strength, balance, and reduce fall risk.
• Mental Health Support: Addresses psychological issues like depression and anxiety.
• Medication Management: Ensures correct medications and dosages.
• Improved Quality of Life: Enhances independence and dignity.
• Coordination of Care: Ensures seamless transitions between different care levels.
• Joint Strategic Needs Analysis for Warwickshire indicates that we have a growing, ageing population who have increasing levels of dependency.
• As health and care services, our aim is to understand and adequately respond to these challenges, to ensure our services are fit for the needs of our populations.
• Apollo Collaborative Primary Care Network consists of five practices working together with a range of local providers, including primary care, community services, social care, and the voluntary sector, to offer more personalized, coordinated health and social care to their local populations.

Physiotherapist/Occupational Therapy

• Falls history/ Falls Assessment
• Social history/Support
• Mobility & Transfers
• Range Of Movement Assessment
• Activities of Daily Living Assessment
• Therapy team assess whether the patient requires a home visit

Assessments

• Full holistic assessment
• Physiotherapy and occupational therapy assessment completed
• Objective assessment
• Upper limb, lower limb and spinal assessment
• Range of movement
• Muscle power
• Balance assessment – Tinetti score
• Chest Physio – managing long term conditions

Outcome measured used

Areas Tinetti will assess:

• Sitting balance
• Sit to stand
• Standing balance
• Balance without visual field
• Balance turning on the spot
• Balance during ‘nudge test’
• Stand to sit ability

Tinetti Assessment

• Assess Balance and Gait
• It is the test most often used with an elderly population therefore very appropriate for the frailty clinic
• Very good reliability and high sensitivity
• Studies have shown it identifies 93% of fallers
• Mostly use balance score in clinic due to space and timings

Clinical Pharmacist at Frailty Hub

• The clinical pharmacist main responsibility is to complete a medication review, optimise medication, deprescribe when appropriate, and ensure safe and effective prescribing.
• The focus in frailty is on key issues surrounding polypharmacy, risk of falls, optimising dosage regimes to reduce the burden on patients.

ACP/ GP in Frailty Hub

• Complete review with patient
• Physical, Mental, Social
• Checking QOF codes
• Check onward referrals
• RESPECT Form 
& Advance Care Planning
• Chest examination
• Cardio- Respiratory examination
• CNS examination
• Initial GIT examination
• GU examination/assessment
• Skin assessment
• PHQ
• 6CIT
• ACP/GP action plan