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NHS@home - Frailty pathway

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


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)



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.

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.

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