Integrated working - the New Forest Frailty Support Service | In Practice Blogs

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Integrated working - the New Forest Frailty Support Service

As we work towards fully integrating Southern Health NHS Foundation Trust and Hampshire County Council’s reablement services to create a single, countywide intermediate care service, it’s important to take inspiration from great examples of integrated working already taking place in the County.

West Hampshire NHS Clinical Commissioning Group, Hampshire County Council, South Central Ambulance Service NHS Foundation Trust (SCAS), and Southern Health NHS Foundation Trust have been working together since October 2016 to improve how we respond to frailty in the New Forest, which is home to the highest concentration of older people in Hampshire.

Working together, they developed the Frailty Support Service which launched in 2017. The service ensures that elderly people in the New Forest area receive health care and social care support in their own homes as far as safe as appropriate. By treating patients at home, teams can spend more one to one time assessing an individual’s needs in an environment they feel safe and comfortable in and which reduces the need to visit their GP or call emergency services for help.

To date, the service has helped over 2,300 people to stay at home instead of needing to go into hospital, and has eased pressures on GPs by avoiding more than 2,000 unnecessary GP home visits.

Some of the core elements of the service include:

  • comprising multi-disciplinary dedicated frailty teams which are made up of colleagues from all four partners;

  • providing clinical assessment and intervention as well as short term support;

  • accepting referrals directly from GPs, SCAS, 111, Hospital Geriatricians and Community Care Teams (District Nursing)

  • responding to referrals within two hours and delivering support within 24 hours of referral.

To find out more about the service take a look at this presentation which was shared at the 2019 NHS Health and Care Innovation Expo.

To contact the fraility support team, call 01590 663257