Integrated Frailty Service




In 2019 the PCN launched their Integrated Frailty Service, building on work practices had been undertaking individually up to that point.

The Integrated Frailty Service is provided by a specialised nurse team who work closely with GPs and other professionals to improve care for older people living with complex health and domestic care needs. They visit people in their own homes and those who live in care homes, aiming to anticipate health and care needs to keep people as healthy as possible at home.


What does the Integrated Frailty Service Do?

  • Undertakes weekly care home ward rounds for all care homes in West Dorset.
  • Assesses needs to help people live healthily at home.
  • Provides education for the individual and their carer about conditions and how to recognise and manage symptoms.
  • Helps the individual and their carer identify if extra services are needed at home.
  • Develops and reviews a Personalised Care Plan with the individual, their relatives and carers and health and social care professionals.
  • Liaises with GPs and other health and social care staff to ensure they understand the support the individual needs.
  • Refers the individual to any services that may benefit them e.g. Community Matrons, Social Services, Consultant Geriatrician, Voluntary Agencies.

What is a Care Plan?

  • Care Plans are personalised plans developed by the Integrated Frailty Nurse and individual. Family members or carers may also be involved in these discussions.
  • A Care Plan will contain relevant health information that will help other health professionals to understand individual needs and wishes.
  • In communicating information through a Care Plan other services are better able to understand and recognise personal health and care needs holistically and assist the individual in meeting these needs.

Future Service Developments

  • Throughout the COVID-19 pandemic the Integrated Frailty Team have adapted their model to include an element of reactive home visiting where required.
  • In 2020 this home visit offer will develop and continue and where appropriate, a member of the Integrated Frailty Service will undertake home visits which would previously have been conducted by a GP.
  • The benefit of including this reactive home visiting element to the service is that it provides improved continuity of care and health outcomes for the individual, allowing the team to not only plan proactively for care needs but respond directly to an acute health need or deterioration in the individual’s condition.