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Ageing Well Team


Our Service:

The team consists of, occupational therapists, community matron, physiotherapist, and care coordinators. We aim to provide a multidisciplinary team approach for patients with mild/moderate frailty, dementia, and those experiencing mental health decline. We will provide a comprehensive assessment for patients who are housebound or would benefit from a home visit to identify their health and social care needs.

Our service aims to keep people with frailty needs, as well as possible in their own homes, and maximising quality of life. By providing a reactive and proactive approach to care, we aim to reduce GP pressure.  We anticipate that between 1-3 visits will be required which will allow us time to carry out a detailed assessment, deliver interventions, make onward referrals, and signposts to appropriate services.

In addition to accepting direct GP referrals, we will offer a proactive approach to identify patients from the GP register. Example of searches already completed include providing assessments for people who:  

  • are housebound with severe frailty.

  • have a dementia diagnosis and have not engaged in their annual dementia review.

Referral Criteria

How to refer:

  • EMIS – please send referrals to the PCN Hub using Accumail

  • SystemOne – please task the Ageing Well Task Box, through the PCN Hub.

  • Please do not add referrals to the ledger.  All referrals will be triaged daily by an Ageing Well Team Member and will be allocated for assessment by the appropriate healthcare professional. Patients will be contacted within a week and visits prioritised according to clinal and psychological need. 

Inclusion criteria

  • A decline or change in cognition, physical or mental health for patients that requires a home visit.

Exclusion criteria

  • Rapid response.

  • Acutely unwell/GP need (consider Neighbourhood Team, Home Ward, or SPA for mental health

  • Those requiring on-going input.

  • Fast track request

  • Input into care homes

  • Unable to provide daily support visits or rehabilitation (this is the Neighbourhood Team or SPA for mental health services)

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