People living with frailty in Yate and Kingswood South are to benefit from a new community service to help maintain their independence and reduce their need for emergency hospital admissions from the end of October.
The pilot Community Frailty service has been commissioned by NHS South Gloucestershire Clinical Commissioning Group (CCG) and targets people living with frailty who are identified as needing extra help and support.
The service is delivered by a multidisciplinary team of therapists and other staff, led by a GP specialising in people living with frailty. The team will have a GP, Physio, Occupational therapist, Assistant practitioners, Dietician, Community psychiatric nurse and Social care assistant to meet the needs of this cohort of service users.
People, who are identified as requiring additional support whether housebound or in a care home, receive a comprehensive specialist assessment of their needs supported by a tailored care plan delivered by community healthcare teams from Sirona care & health.
Referrals will come to the team from their GPs, in discussion with the practice multidisciplinary team, as well as the complex assessment and Rapid access services in North Bristol Trust.
The service will be available five days per week during office hours and outside of these hours urgent cases will be referred to an out of hours GP service.
Dr Ann Sephton, Deputy Clinical Chair for the CCG and GP in Cadbury Heath said: “South Gloucestershire has an ageing population with increasingly complex needs leading to ever rising numbers of people needing urgent or emergency care.
“By providing tailored services for these patients, we know we can increase their independence, health and well-being so that more people can stay in their homes and not need to be admitted to hospital for conditions that could be prevented.
“We anticipate that approximately 100 fewer patients per year will need to be admitted to hospital as a result of this service.”
The community frailty service will be piloted for 12 months on a test and learn basis. If the pilot is successful, the aim is to expand the service to all patients registered with a South Gloucestershire GP practice who are living in care homes or who are housebound.
Alison Griffiths, Sirona’s Locality Manager for Kingswood, said “This is an innovative way of supporting people living with frailty to maximise their independence and improve their quality of life as well as to reduce admissions to hospital and long term care facilities.
“The project has been set up with engagement from South Gloucestershire Council, Avon & Wiltshire Mental Health Partnership, GPs and other Sirona services in a way that has not been tried before. All partners are working to improve the care provided to individuals with frailty, and work together in a more joined up way.”
The community frailty service will sit alongside and enhance South Gloucestershire’s current community health services already provided by Sirona care & health. This will enable a seamless transfer to the most appropriate service to meet the individual’s needs.