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Single Point of Access for Frailty

Enhance frailty care coordination with a single point of access for urgent and non-urgent referrals, providing tailored pathways for patients. Comprehensive services available from Monday to Friday, with after-hours support. Collaborative approach with dedicated nurse screening and rapid response services.

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Single Point of Access for Frailty

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  1. Single Point of Access for Frailty Kevin Pollard Clinical Lead, Rapid Access Services, CNWL Virginia Franklin Project Manager for Frail and Elderly Integration, Haverstock Healthcare Ltd

  2. Rapid Access Services

  3. Single Point of Access • Frailty SPoA due to go live in October 2016 • Monday to Friday, 9-5pm for non-urgent and urgent referrals • Out of hours ‘urgent’ referrals diverted to Rapid Response – 24/7 cover • Dedicated phone line direct to senior frailty nurse screener (in hours) • ‘Clinician to clinician’ discussion and screening for the most appropriate pathway for the patient.

  4. Refer In Refer In RoyalFree London Ambulance Service Self/carer/ relative University College Hospital SPoA Referral Pathway REDSTeam Long term conditions teams PACE Team District Nursing Rapid Response Team GP Frailty SPoA Referrals into FE SPoA Refer Refer Assessment by frailty nurse screener Social services Long term conditions District nursing MDT Locality or Hub Rapid Response Complex care nurses

  5. Single Point of Access & MDT • Referral into Frailty Nurse Screener for MDT assessment • Screener can refer directly to an MDT, depending on need • Three levels of assessment, mild moderate and severe

  6. Non-urgent frailty referral Example Case Study • “An 80 year old female with bilateral knee osteoarthritis and ischaemic heart disease. Has carers who support with domestic ADLs and provide some assistance with personal care, and is able to go out on a wheel chair/uses a frame to mobilise indoors. She is now beginning to develop increasing problems with indoor mobility, and has had two falls. Also developing some mild problems with memory and is finding it difficult to manage her bills/medication.” • Screened and assessed as moderately frail. Referral made to locality MDT

  7. Urgent frailty referral Example Case Study • “An 87 year old gentleman referred by GP with a history of Alzheimer’s, heart failure. Presenting with an acute chest infection and functional decline. Lives with wife and daughter and has a 4x daily care package. Normally mobile short distances with a frame, however now bedbound.” • Assessed by frailty nurse screener. Deemed as being at risk of hospital admission, requiring urgent intervention. Referred to Rapid Response.

  8. Rapid Access Services

  9. Future plans • Frailty SPoA: Developing referral pathway to Over 75’s GP home visit service • Reablement: integration of health and social is an ongoing project in Camden and the future SPoA may include all reablement services • Informing commissioning intentions: Identifying ‘what we don’t know’ missing provision and pathways (the unmet needs)

  10. Any questions?

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