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Frailty Programme

Our Frailty programme is helping to improve the health, independence and well-being of High Weald Lewes Havens residents and supporting GPs and other health professionals to much more effectively identify and care for people with frailty.  In moving away from a reactive way of working, we are taking a much more proactive approach which is personalised and patient centred, as well as making better use of valuable resources and reducing people having to go into hospital unexpectedly.  A key aim is to support older residents to live independent and healthy lives.

A central feature of the programme is our Frailty Service, comprising of a Community Geriatrician service and a Frailty Nurse Specialist service.

In place since 2014, initially as a pilot service in The Havens area,  Consultant Geriatricians support GPs to manage patients with frailty and complex needs through community clinics, home visits, and support to our community hospitals. A review in early 2016 provided evidence of the significant benefits of the Service, including reductions in both people going to A&E and having to go into hospital unexpectedly, which we presented at the British Geriatric Society 2017 Conference.  Following its initial success, we expanded the Community Geriatrician service in 2017 to cover the whole of the CCG.

The introduction of the Frailty Nurses in spring 2018, has expanded the access to frailty specialists for our residents still further. Four highly skilled nurses, working alongside the Community Geriatricians, now also offer specialist advice to GPs and their practices and deliver comprehensive support to patients - such as providing clinical assessments, proactive care planning and care coordination which includes making referrals onto other care services and professionals.

While we want to support people in their own home for as long as possible, if this is no longer possible we need to ensure that the best possible care is provided to those in residential settings. The main focus of our new Enhanced Health in Care Homes service is to bring improved and proactive GP services to the residents of nursing homes in High Weald Lewes Havens.  Our aim is simply that nursing home residents receive the best possible care, in the right place, at the right time – by making people healthier and maintaining health, reducing unnecessary hospital admissions and enhancing care for people towards the end of their lives.  The Enhanced Health in Care Homes service has been introduced gradually across nursing homes in High Weald Lewes Havens during 2017 and 2018. 

A key foundation for the CCG is that our residents nearing the end of life should receive the care and support they need to enable them to live to the end in the best way that they can. 2018 has therefore also seen the introduction of our ‘Vision for End of Life Care’. This framework sets out how we will deliver our ambition to provide joined-up, responsive, person-centred services which are timely, seamless and provide high quality care and support at the end of life in accordance with people’s wishes and preferences.

Further information about all of our frailty programme work streams can be found in HWLH CCG’s Frailty Strategy. 

You can make a difference.

For more information or to get involved please email hwlhccg.enquiries@nhs.net or telephone 01273 485300.