REMEDY : BNSSG referral pathways & Joint Formulary

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Checked: 23-02-2023 by Vicky Ryan Next Review: 23-02-2024

Practice-based frailty multidisciplinary team (MDT) meetings

For Frail patients requiring urgent care or possible admission then please see the Frailty - Urgent Care page.

NBT offer a Geriatric Medicine A&G service covering Cognitive disorders, Falls, Bone health  and Osteoporosis for Older People (BHOOP) and Movement Disorders.

For routine or planned care then please see below:

MDT meetings

Sirona are working in an integrated way with practices to help prevent frailty progression in our older, more vulnerable patients. The MDT meetings themselves are an opportunity to discuss difficult cases, share learning/clinical risk and make an action plan for high risk patients. Patients may be taken onto the integrated network team caseload where short term clinical input is required, with the aim to stabilise and support patients to self-manage their long term conditions.

The ACP will gather helpful information, such as elements of a comprehensive geriatric assessment (CGA) in advance of the meeting to ensure a good discussion can occur. This process may be carried out remotely during Covid19 restrictions. The CGA involves an assessment of all elements of health:

  • physical/mobility/balance
  • functional/social/environmental (ADLs, continence)
  • psychological (mood and cognition)
  • medical/medication

Patients with a Rockwood (Clinical Frailty) Score of 5 or above and any of the below might be appropriate for discussion at MDT meeting:

  • Frail patients at “tipping point” and at risk of deterioration/decompensation/not coping, especially if self-neglect, non-compliance, carer fatigue/crisis, multi-morbidity
  • Complex end of life
  • High impact users (hospital admissions/A+E/999/111/OOH/GP/rapid response)
  • Recent hospital discharge/admission
  • Any older patient you feel would benefit from additional multidisciplinary input (identified opportunistically or via search for severe frailty eFI/practice frailty register)

Suggested core MDT team members

  • Sirona ACP (community matron) +/- community nursing team representative
  • Sirona ward clerk/administrator (to type up minutes, coordinate meeting, liaise with various agencies, arrange agreed referrals)
  • GP (practices choose how they run this – GP who knows patient best, lead GP or rotate GPs)
  • Community Rehab Team representative (OT/physio)
  • Social care representative

Suggested extended membership of MDT (invite for selected patients where relevant)

  • Social prescribing lead (named lead for each PCN from December 2019)
  • Sirona active ageing nurses (should be in post from April 2020 – inviting all over 85s for assessments)
  • Other care providers (practice nurse, pharmacist, dietician, podiatrist, mental health, private carer/care home staff, dementia advisor, hospice team, voluntary sector representative)

Referral to Frailty MDT

Email Sirona SPA:

from account, copying in the MDT Frailty Team (details on the referral form), using the referral form in EMIS or using the OC MDT Frailty F12 protocol (South Gloucestershire). This will launch the OC MDT frailty referral template which allows you to enter the following information:

  1. Reason(s) for referral
  2. Background information
  3. Expectations/desired outcome from referral
  4. Rockwood score if known (becoming common parlance for frailty and is used by ambulance, hospital and community nursing services so we probably need to become familiar with it)
  5. Has the patient consented to referral, or if they do not have capacity, are you proceeding in their best interests (consent/BI)?

The protocol then automatically creates the OC Frailty MDT referral form. For consistency, we suggest you task your admin team to email the referral document to the SPA (email addresses and instructions are on the referral form). We also suggest creating a virtual MDT “surgery” on EMIS – the ward clerk/coordinator can then book patients in here for the next meeting.

Local contact details including Ward Clark/Coordinator for your PCN should be available at your practice.

Medication Review Tool for Polypharmacy in the Elderly

A BNSSG medicines optimisation guideline for reviewing medication in the elderly (primarily in the care home setting) has been developed and can be found in the Formulary Section of Remedy here.

Frailty & Type 2 Diabetes

Refer to the Diabetes and Frailty - assessment of risks and benefits of therapy - guidelines for clinicians.

These guidelines give advice on management of diabetes in frail patients where the normal HbA1c targets may not be appropriate. The key aim of treatment in frail patients or those nearing end of life is avoidance of hypoglycaemia and hyperglycaemia which can increase hospital admissions, aggravate co-morbidities and reduce quality of life. The above guidelines give pragmatic advice on how to manage this group of patients.

The BNSSG diabetes team have advised that for QoF purposes an exception code (they suggest 'maximum tolerated treatment for diabetes') can be used for patients where tight HbA1c control is not appropriate.


Please see the separate Remedy section on Dementia

Urgent Care

In any situation where you need urgent advice or feel that admission is likely please see the Frailty - Urgent Care page.

When making a shared decision about whether to admit, please also consider using the Admission Reflection Tool.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.