Aspen Medical Practice Frailty Team Model

Aspen Medical Practice has a total practice population of over 31,000 with high deprivation and disease prevalence in Gloucester City, of which 5,000 are aged over 65 giving us a significant number of high intensity users and demand for GP home visits. Whilst delivering over 250,000 consultations per year for a large, ageing, population with increasingly complex issues, we identified the appointment of a clinician to focus on health and well-being in older, frail, patients (not living in residential care) as a transformational step in 2017. The intention of this role was to proactively anticipate problems before they happen, thus improving outcomes and reducing avoidable demand for limited healthcare resources. Rachel Bucknell was appointed as Frailty Matron to take on this work and began by using data to ‘map’ patients with dementia, high intensity users, people recognised as housebound and those with a high electronic frailty index score. This cohort forms the core patient group. From initially working solely on direct GP referrals, we opened referrals to the other members of the clinical team. This led to the creation of the Aspen Frailty Team, which now includes 2 senior GPs, a second Frailty Matron and 2 social prescriber/HCPs. The team is supported by our Clinical Director. There are regular Multi-Disciplinary Team meetings, which are attended by Community Nurses from the local provider trust. Taking a wider partnership approach, we also engage with a wide range of community services and voluntary organisations. Having addressed immediate health/wellbeing issues, we begin working with the patient and their carer(s)to plan for the future (Advance Care Planning) , using tools such as ‘Me at my Best’ frailty plan (as early adopters), and the ReSPECT form. Key highlights: Our proactive care approach has reduced unplanned admissions and requests for urgent visits by GPs. Improved primary-secondary care interface with better communication and information sharing. The team provides an additional point of contact for carers/relatives reduces pressure ‘at the front door’. We have created a seamless overlap with in-house Mental Health and Learning Disability teams in our ‘team of teams’ approach. Improved take up of COVID-19 vaccinations in vulnerable patient groups. Key learnings: Remote access to the hospital’s ‘Sunrise Go’ system allows us to identify patients who have been admitted to hospital and those who may need a post discharge review in a timely manner. Understanding what happens to patients during admissions is vital. Effective communication between primary and acute services drives ‘productivity’. Addresses health inequalities by improving access to vaccinations and health checks for housebound and elderly people. Drives continuity of care and in-depth knowledge of patients and their social situation, allowing much more appropriate and tailored care and advice to be delivered. With the Frailty Team now well established we will continue to expand team and widen our scope of practice, and building on our partnership work across the public, voluntary and community sectors to achieve the best possible outcomes for our patients and their families.