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.

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