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NHS@home - Frailty pathway

Checked: 23-11-2023 by Vicky Ryan Next Review: 23-11-2024

Overview

The NHS@Home Frailty team provides clinical care for frail older people who are experiencing an acute deterioration, in their own homes across BNSSG.

Who are we?  Advanced Clinical Practitioners specialising in frailty, multidisciplinary healthcare professionals from the collaborative BNSSG NHS@Home team, working with Specialist Consultants from NBT and UHBW.

How does the service work?

The service uses a mixture of digital remote monitoring up to four times per day (NEWS2 and bespoke questionnaires) visible on a virtual ward dashboard, telephone and video support, and face to face visits from specialist healthcare professionals. Weekday multidisciplinary virtual board rounds supported by specialist Consultants. Access to SDEC/alternatives as required.

What enhanced skills does the service have? 

  • Ability to undertake complex geriatric assessments
  • Access to consultant geriatricians with interest in frailty

Who is suitable for an NHS@Home Frailty pathway of care?

The service is suitable for adults who:

 

This service is not suitable for adults who:

  • Meet the general criteria for an NHS@Home pathway
  • Adults over >=65 with a clinical frailty score of >=5 (clinical discretion allowed)

  

Referral

In addition to the pathway specific criteria above, the standard criteria on the NHS@Home overview page need to be met.

To refer to this service, please refer to the NHS@Home overview page.



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