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High level outline of frailty services
Patients frailty and dependence
Likely to be living at
home with support
Likely to be living
Likely to be living in a care
home or dependent on
Likelihood of inclusion in 2% care planning DES patient cohort
Unlikely to have a care plan
Sirona Active Ageing
Service for residents
aged 80 - 84
* Criteria for doing so could
include age > 84 or ED visit
GP carries out
rapid access for
carried out by
carried out by
Assessment changes to care
GP visit to care
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
蔡依珊醫師-放診專 682 / 林佳穎醫師 * Antegrade pyelography Clinical: Left UPJ stenosis wtih hydronephrosis s/p PCN Findings: >Preliminary film shows acceptable position of left PCN. >Well opacification of left collecting system. >The left renal pelvis and calices are dilated. Left ...
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