Frailty care and core features

General assessment

Social Care review

Carers and relatives

Video outlining the core elements of a clinic for people living with frailty

Frailty is defined in many ways and can affect any age. One practical definition is the combination of mobility problems, a need for carer support and often memory problems (impaired cognition).
People living with frailty often have multiple health problems that are hard to address within the seven, face to face, minutes of a ten minute GP consultation. It requires an integrated team approach to identify all the issues, complete actions, prevent a crisis, and prevent possible admission to hospital.
There are three core elements to a wellbeing clinic for people living with frailty:

General Assessment

There needs to be sufficient time to review all the issues and make an initial plan on how to tackle each issue. An hour is a minimum for this.
A key step is to access and review the primary healthcare records, which are usually comprehensive and up to date.
Most issues and actions can be planned from existing records then added to with the individual person and their carers or relatives.
A shared care plan and follow up of actions is important.

Social care review

A review of social care is a big step forward from what can be provided in primary care at present. This takes at least thirty minutes with a person who has good knowledge of the social care system. Someone who can advise on house adaptions to improve safety and self-care, along with advice on benefits, life documents and carer support.
This is the missing link in the healthcare sector and can help bring in key support from the voluntary sector.

Carers and Relatives

The support network to enable a person living with frailty to stay at home is important. Involving relatives and other carers in the review will establish a shared understanding and shared plan that often opens up new options for allowing someone to stay in their own home, safely.
A frailty clinic can often bring much needed information and support for carers under long term pressure from their role.