Frailty Multi-Disciplinary Team




Healthwest is working in an integrated way with Sirona community services to help prevent frailty progression in our older, more vulnerable patients. We hold monthly virtual Multi-Disciplinary Team (MDT) meetings lead by a nominated community Advanced Care Practitioner (ACP). The key members that attend the MDT include:

  • Sirona ACP (community matron) +/- community nursing team representative
  • Sirona ward clerk/administrator
  • A lead GP, or any referring GP's
  • Community Rehab Team representative (OT/physiotherapists)
  • Social care representative

image of a carer

These meetings are an opportunity to discuss difficult cases, share learning/clinical risk and make an action plan for high risk patients. Patients may be taken onto an integrated network team caseload where short term clinical input is required, with the aim to stabilise and support patients to self-manage their long term conditions.

The ACP will gather helpful information, such as elements of a comprehensive geriatric assessment (CGA) in advance of the meeting to ensure a good discussion can occur. This process may be carried out remotely during Covid19 restrictions. The CGA involves an assessment of all elements of health:

  • physical/mobility/balance
  • functional/social/environmental (ADLs, continence)
  • psychological (mood and cognition)
  • medical/medication

If you feel that you or a loved one could benefit from Frailty MDT input, please discuss this with your GP