1. Single Point of Access for Frailty Kevin Pollard
Clinical Lead, Rapid Access Services, CNWL
Virginia Franklin
Project Manager for Frail and Elderly Integration, Haverstock Healthcare Ltd

2. FE Single Point of Access (SPoA)
Rapid Access Services
FE Single Point of Access (SPoA)
PACE
REDS
Rapid Response

3. Single Point of Access Frailty SPoA due to go live in October 2016
Monday to Friday, 9-5pm for non-urgent and urgent referrals
Out of hours ‘urgent’ referrals diverted to Rapid Response – 24/7 cover
Dedicated phone line direct to senior frailty nurse screener (in hours)
‘Clinician to clinician’ discussion and screening for the most appropriate pathway for the patient.
Add un-met need – unsure referral.

4. Frailty SPoA SPoA Referral Pathway University College Hospital
London Ambulance Service
Royal Free GP
REDS Team
Rapid Response Team
PACE
Team
District
Nursing
Refer In
Long term conditions teams
Self/carer/ relative
MDT
Locality or Hub
Rapid Response
District nursing
Complex care nurses
Long term conditions
Social services
Assessment by frailty nurse screener
Refer
Referrals into FE SPoA

5. Single Point of Access & MDT
Referral into Frailty Nurse Screener for MDT assessment
Screener can refer directly to an
MDT, depending on need
Three levels of assessment, mild
moderate and severe

6. Non-urgent frailty referral
Example Case Study
“An 80 year old female with bilateral knee osteoarthritis and ischaemic heart disease. Has carers who support with domestic ADLs and provide some assistance with personal care, and is able to go out on a wheel chair/uses a frame to mobilise indoors. She is now beginning to develop increasing problems with indoor mobility, and has had two falls. Also developing some mild problems with memory and is finding it difficult to manage her bills/medication.”
Screened and assessed as moderately frail. Referral made to locality MDT

7. Urgent frailty referral
Example Case Study
“An 87 year old gentleman referred by GP with a history of Alzheimer’s, heart failure. Presenting with an acute chest infection and functional decline. Lives with wife and daughter and has a 4x daily care package. Normally mobile short distances with a frame, however now bedbound.”
Assessed by frailty nurse screener. Deemed as being at risk of hospital admission, requiring urgent intervention. Referred to Rapid Response.

8. Rapid Access Services
REDS - Up to 6 week programme of therapy and Carelink re-enablement to facilitate early hospital discharge and reduce long term care burden.
FE Single Point of Access – 5 day service for frailty and/or complex patients. Clinical assessment of referrals to agree appropriate pathway, which may be MDT.
PACE – 5 days early supported discharge from the RFH for medically unwell and therapy patients. Includes 7 day PACE Step-down if needed.
Rapid Response – 10 day service for admission prevention. MDT approach to supporting acutely unwell patients at home.

9. Future plans
Frailty SPoA: Developing referral pathway to Over 75’s GP home visit service
Reablement: integration of health and social is an ongoing project in Camden and the future SPoA may include all reablement services
Informing commissioning intentions: Identifying ‘what we don’t know’ missing provision and pathways (the unmet needs)

10. Any questions?