Livewell Southwest is working with a Plymouth GP practice (Pathfields Medical Group) and University Hospitals Plymouth NHS Trust to support frail older people to remain happier, healthier and independent, and reduce the need for unnecessary admissions to hospital.
A team of district nurses, social workers, therapists and doctors use an assessment to keep older people with moderate to severe frailty active, happy, healthy and independent for as long as possible.
Offering short intensive support, the team focuses on the person’s issues and goals to create a care plan, which can include signposting to third and voluntary sectors where appropriate. The care plan is shared with the person, Devon Doctors and South Western Ambulance Service so they receive the best care.
Consultants from University Hospitals Plymouth NHS Trust also identify patients with frailty issues who might benefit from support from the team when they leave hospital.