Hundreds of people from the western side of the New Forest are benefitting from a Frailty Support Service led by Southern Health NHS Foundation Trust (SHFT) and funded by NHS West Hampshire Clinical Commissioning Group (CCG).
In its first year, more than 300 frail or elderly patients were treated in their own homes when they became ill with only 75 people needing to go into hospital. The service also saved 200 GP appointments.
Following a successful pilot last year the Frailty Support Service has now been funded permanently with the aim of preventing unnecessary hospital admission and delivering effective care closer to home. It is led by Southern Health NHS Foundation Trust working in close partnership with South Central Ambulance Service NHS Foundation Trust, Hampshire County Council and GPs with support from local hospital League of Friends.
Debbie Crewe, Consultant Practitioner in Frailty for the Frailty Support Team said: “This new team means we can come together as professionals to look at the patients’ pathway more holistically. More than 95 per cent of our referrals come from GPs and the ambulance service, so sending the FST mobile team means we can contribute to relieving pressure on the whole of the local NHS system.
“Say a patient with reduced mobility can’t get out of bed, they would have historically called a GP or an ambulance and potentially ended up in hospital, we now offer a rapid assessment in their own home. When doing so, we can identify other concerns, such as equipment needs, medicine compliance and any other support that maybe needed to achieve a patient centred care approach in keeping the patient within the community safely.
“Some patients still need to go to hospital for further diagnostic testing like x-rays, but often we can bring them into Lymington Hospital, rule out the risks and get them back home again within the same day. Another huge change is the support we provide to the family in their relatives’ care.”
Maggie Harmer’s mother received care from the Frailty Support Service last year after her mother was in great pain and unable to get out of bed.
“Ambulance Technicians and a nurse arrived at my mother’s home 15 minutes after I called my doctor’s surgery. The team examined by mother and arranged for her to be seen at Lymington New Forest Hospital, which was so much easier than going to Southampton General.
“She came home the same day, but she also had some thorough tests which showed she had dementia, which we had no idea about. She was then seen every day for the first week by the Frailty Support team. The service is a real asset to the area and without this extension of care she would definitely not be as well now, or able to live at home.”
Mark Browning, Demand Practitioner from South Central Ambulance Service, added: “As ambulance crews in the local areas we have the referral criteria for the frailty team and when a patient rings in, we can assess whether it’s life-threatening or more appropriate for the frailty team to be consulted. We’ve often found that as ambulance staff we think they may need a hospital admission.
“As part of the Frailty Support Service, we are now discussing the patient’s case with the frailty consultant, we have options to help them in their home so the patient gets the right support without the requirement for an ambulance, so it works all around.”
Johnny Lyon-Maris Clinical Primary Care Lead from West Hampshire Clinical Commissioning Group said:
“This is a service that has been supported universally by the practices and GPs of the New Forest. It has had a significant positive impact on patients, allowing them to remain at home when it is clinically appropriate, and reducing the pressure on the patients practices with its urgent and follow-up care streams. We are hoping to extend this approach to provide outreach to more of our patients, as it is an outstanding service for the community.”
The team currently operates Monday to Friday but aims to support frail patients seven day a week as it expands following its current recruitment process.