Abstract
Abstract Introduction Surrey Downs Health and Care (SDHC) is an innovative partnership between acute and community providers, local general practitioner (GP) federations and adult social care. The NHS Long Term Plan emphasises the importance of ageing well and supporting people living with frailty by improving integrated proactive services in the community. To achieve this, SDHC collaborated with local Primary Care Networks (PCNs) to develop a frailty multidisciplinary team (MDT) to deliver proactive virtual Comprehensive Geriatric Assessments (CGA). Method A monthly frailty MDT meeting was introduced across two PCNs. MDT members included a geriatrician, GP, frailty nurse, community matron, district nurse, therapists, social prescriber, paramedic practitioner and social worker. A reactive-proactive model was utilised; patients over 65-years-old already referred to the community teams were proactively screened for frailty and scored using the Clinical Frailty Scale (CFS). Patients that scored 6 and above were discussed at the MDT and a virtual CGA completed. Results 151 patients were referred for MDT discussion over eight months. Patients had a mean age of 86 years and a modal CFS score of 6. In the 8-weeks following MDT discussion compared with the 8-weeks prior, patients attended 11% fewer GP consultations, a 9% decrease in community visits and 30% fewer emergency department (ED) attendances. Conclusion The implementation of a dedicated PCN frailty MDT who conducted proactive CGAs reduced patient attendance to ED and resulted in fewer consultations with community services. This success has led to a system wide implementation of the model to the other local PCNs.
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