Since April 2012, more than 250 of Camden’s most vulnerable frail patients have been supported by the Camden-wide Frailty Team.
The Complex Care Locally Commissioned Service (LCS) was re-launched to help GP practices better identify and assess frail patients and improve the planning and coordination of care for patients in practices. Led by a GP, the Multidisciplinary Team (MDT) includes input from geriatricians, hospital and community-based nurses and allied health professionals, social workers and mental health workers. Working together across primary, secondary and community health and social care providers, the team has planned and coordinated care for patients who have the most complex health and social care needs.
Since the re-launch, 830 of Camden’s most vulnerable frail patients have been identified and benefited from improved care planning. Analysis has shown that patients were able to spend more days at home in the six months after receiving support from the Frailty Team. This equated to 50% fewer days in emergency beds and a reduction in A&E attendances of almost 50% for this group of patients. The number of first and follow-up hospital outpatient appointments has also reduced by 50%.
This film provides an overview of the challenges and issues that led to the establishment of the MDT as well highlighting the work of the Team with a personal story from a patient who they support.