The Provision of Primary Care Enhanced Frailty Service for NWL CCG - Harrow Borough

Descriptions

The North West London Borough of Harrow requires an Enhanced Frailty Service to provide direct delivery of services for people experiencing frailty within the Harrow population, coordination of the system response to these elements through partner organisations and bringing together wider primary care commissioned services through the PCN DES services, in order to achieve the streamlined delivery of services. The Enhanced Frailty Service thus aims to provide a wrap-around service for frail venerable patients, with General Practice (GPs) at the heart of the service model, supported through a multi-disciplinary team of professionals. A patient's registered GP will provide the central service offer and will draw upon the wider expertise within primary care and the wider community and acute services. The service will be achieved through the delivery of a three-tiered approach: • Tier 1 - core General Practice services are at the heart of our health care system and are the first point of contact for patients. A patient's registered GP will provide the central and core service offer for the management of frail patients. This service is provided through a GP's Core Contract. • Tier 2 - comprises of both a proactive and reactive arm. Patients will escalate to an enhanced primary care service at tier 2 as their risk factors or needs escalate and they require a more proactive response. In Tier 2, the service will be led by an appropriately qualified Frailty lead for each PCN, who will work closely with the individual practices frailty lead. • Tier 3 - component of the service is a Primary Care led multidisciplinary team (blended and adaptable depending on patients need). The multi-disciplinary teams will provide care for the most complex of the patient cohort groups, ensuring continuity and care longevity. The tier 3 service element will be overseen by the PCN frailty lead with ready access to patient registered GP and with access to the wider MDT for support to the most complex of patients. The service will provide holistic care by carrying out comprehensive geriatrician assessment; identification of escalating needs; personalised medication review; connection to resources in the community; care Coordination; Multi-agency input (MDT); and intervention to avoid deterioration and hospital conveyance.