Pro-Active Frailty Healthcare Service - North East Lincolnshire

The service identifies frail patients from a registered population within a Primary Care Network (PCN) and undertakes a Comprehensive Geriatric Assessment (CGA), generally in the patients place of residence, developing a care plan for each patient and referring to appropriate services. Individuals with a clinical frailty score (CFS) 7+ (post assessment) will be offered annual reviews, including proactive identification of those who are likely in the last year of life. The aim of the service is to provide proactive care to support frail patients to remain as well as possible as well as documenting advanced decisions through ReSPECT forms. Regular MDTs will be held to discuss patients' needs and identify support required.