Integrated Frailty Service




PCN Integrated Frailty Team

The Integrated Care (Frailty) Team are a service that provide assessment, guidance and support to individuals living in their own homes or in care homes. Those who require intervention from the Integrated Frailty Team are those who are living with frailty. This is a medical diagnosis that refers to someone who lacks the reserves to cope with minor changes in their health which may cause them to struggle to remain independent or to require them to need more help and care.

The team will assess the home situation, discuss personal wishes and explore care needs. This includes decisions regarding future planning and wishes regarding treatment. The team can offer guidance, signposting and referral to other services who we believe will be beneficial. We work very closely with other key services within health and social care and the voluntary sector (e.g. charitable organisations) and can access a wide range of support options for patients.

Our Advanced Practitioners work closely with the GP and other medical colleagues and are competent in performing physical health assessment with the aim of diagnosing and prescribing medications if required. The Advanced Practitioners provide regular input within care homes across the Primary Care Network.


What does the Integrated Frailty Service Do?

  • Undertakes regular care home ward rounds for all care homes in the Primary Care Network.
  • 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. Social Services, Specialist Health Services, 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

  • The service are developing their working relationship with the Pharmacy Team and Social Prescribing team to offer a more integrated approach to medicines management and Personalised Care Planning.
  • The team continues to develop the staff to promote continued professional development.
  • We are also looking for opportunities to recruit other health care professionals such as allied health professions (e.g. Occupational Therapy) in order to expand our expertise.

Team Members

  • Dr James Ashby – Frailty General Practitioner
  • Sarah Kimber – Advanced Clinical Practitioner, Team Lead, Care Homes Clinical Lead. Registered Nurse. Independent Prescriber.
  • Jolene Stephenson – Advanced Clinical Practitioner (Trainee). Registered Nurse. Independent Prescriber
  • Sarah Parmiter – Senior  Clinical Pharmacist
  • Emma Cochrane – Senior Integrated Care Nurse. Registered Nurse.
  • Rose Simco - Senior Integrated Care Nurse. Registered Nurse.
  • Jen Follett – Apprentice Student Nurse.
  • Teresa Charles – Health Care Assistant.
  • Tracy Laxton – Administrator.