Title Page - www.bristol.ac.uk | University of Bristol

Title Page - www.bristol.ac.uk | University of Bristol

High level outline of frailty services
Patients frailty and dependence
Moderate Frailty
Likely to be living at
home with support

Mild Frailty
Likely to be living
at home

Very Frail
Likely to be living in a care
home or dependent on
carers

Likelihood of inclusion in 2% care planning DES patient cohort
Unlikely to have a care plan

Detailed assessment

Routine assessment
Patients GP
undertakes
Rockwood frailty
assessment*

Sirona Active Ageing
Service for residents
aged 80 - 84

* Criteria for doing so could
include age > 84 or ED visit

June 2015

Highly likely

Detailed
Assessment
Required

Option 1
GP carries out
brief
comprehensive
Geriatric
Assessment

Referred to
rapid access for
assessment
clinic
(Cossham)

Option 2
Assessment
carried out by
Community
Frailty Service

Option 3
Assessment
carried out by
CALS team
following acute
care episode

Identified as
requiring
Detailed
Assessment changes to care
during weekly
Required
GP visit to care
home/home

Care Management by members of Cluster MDT
Shared Care plan available to MDT members
Revised care packages put in place by 1 or more MDT members
Sub-set of frailty patient cohort actively managed by MDT

South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health

1

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