The Community Frailty Service supports patients to live well alongside their existing long-term conditions.
Long-term conditions are described as health problems which need managing over many years.
They are not curable but can be managed well with medication and lifestyle choices.
The Community Frailty Service consists of a multidisciplinary team of health professionals, including doctors, advanced clinical practitioners and pharmacists.
The service has close links with other community services, including your GP, as well as hospital-based services.
As well as providing health support, we are also keen to support your wellbeing. This is achieved by supporting you to set goals that are personal to you.
This service has been developed for patients who have at least one long term health condition including frailty.
Although the term ‘frailty’ can mean different things, when we talk about it in relation to your health, we specifically mean a condition that affects your health. This is like any other long-term health condition, such as asthma or diabetes.
Frailty is recognised by the loss of our physical and/or mental inbuilt reserves. These inbuilt reserves are what our bodies use to recover from illness and injury.
If we lose these reserves, we can be at risk of having a dramatic change in our health and function, even after an apparent minor event, such as a fall or urine infection.
Frailty is a changing condition and we can support you to try and prevent any further deterioration in your health.
You may be referred following a stay in hospital, by your GP or existing community team if it is felt you could benefit from extra support to manage your long-term condition.
You may also be referred following an A&E attendance or if you have needed out of-hours care.
An appointment will be made for you to meet a senior clinical member of the team for an initial assessment.
The appointment will include a non-invasive examination as well as information gathering about how you currently feel and live. The appointment will take up to 90 minutes.
This will give us the opportunity to get to know you better and discuss how the service may benefit you. If you are accepted onto the service, together we will create a plan of care.
Joining the service is completely voluntary.
The service covers the whole Fylde Coast with appointments offered across a number of community clinic settings.
After your initial assessment, you will be visited at home by a member of the team to work through your plan of care.
This may include education and advice to help you to manage your long-term conditions and support you to keep well at home, ordering any necessary equipment to ensure you can mobilise safely and signpost you to any other services that may be of benefit.
We can also offer you a medication review by our Pharmacy team and answer any questions you may have about your medication.
The service also offers a daily telephone triage service to support patients when they feel unwell due to their long-term conditions.
This same day service aims to treat patients at home wherever possible in order to prevent an admission to hospital.
You will remain registered with your GP and will be able to access your Practice in the usual way.
The average length of time with the Community Frailty Service is around 12 weeks.
