Community Frailty Service

Introduction to the Service

The Community Frailty Service is part of Blackpool Teaching Hospitals NHS Foundation Trust. The 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.  As well as providing health support, we also support the patient’s wellbeing. This is achieved by supporting the patient to set goals that are personal to them.

The Community Frailty Service consists of a multidisciplinary team of health professionals, including a Consultant Community Geriatrician & Physician, Frailty GP’s, Nurse Consultant’s, Advanced Clinical Practitioners, a Pharmacy team, Clinical Care Coordination team and Assistant Practitioners.

The service covers the whole Fylde Coast with appointments offered in the home setting or across a number of community clinic settings. After the initial assessment, the patient will be visited at home by a member of the team to work through their plan of care. This may include education and advice to help the patient to manage their long-term conditions and support them to keep well at home, ordering any necessary equipment to ensure they can mobilise safely and signpost to any other services that may be of benefit.

We can also offer the patient a medication review by our Pharmacy team and answer any questions they may have about their 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.

Who is suitable for the service?

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 patients health, we specifically mean a condition that affects their 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 the body uses to recover from illness and injury.  If these reserves are lost 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 patients to try and prevent any further deterioration in their health.

Patients may be referred following a stay in hospital, by their GP or an existing community team if it is felt they could benefit from extra support to manage their long-term condition(s).

Patients may also be referred following an A&E attendance or if they have needed out-of-hours care.

What will happen next?
An appointment will be made for the patient 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 the patient currently feels and lives. The appointment will take up to 90 mins.

This will give us the opportunity to get to know the patient better and discuss how the service may benefit them.

Whilst under the service, the patient will remain registered with their GP and will be able to access their Practice in the usual way.

The average length of time with the Community Frailty Service is around 12 weeks.

To contact the Community Frailty Service for more information, please ring (01253) 951400

Click here to see the Community Frailty Service information leaflet.