Who do we see? Elderly patients who have had a noticeable increase in frailty or reduced functioning, acute illness, exacerbation of long-term condition and/or those at risk of further deterioration and admission to inpatient frailty units. We also provide enhanced nursing support to patients on discharge where there is no significant ongoing DN involvement.
What do we do? We provide a time-limited, targeted assessment and support to vulnerable elderly people during an acute episode of illness or deterioration. We conduct a Comprehensive Geriatric Assessment at home, liaising with members of the multi-disciplinary team to set outcomes of care and promote independence at home. People will be discharged to mainstream services for ongoing management and care as appropriate.
Who can refer? Any healthcare professional, care home staff, pharmacists, GP, Scottish Ambulance Service, Hospital discharge team and Acute Frailty Team
How do we work?
• All calls are triaged, and referrals will be assessed by the cluster nursing team initially. Where an advanced clinical assessment is required, this will be undertaken by an ANP or CNS with medical responsibility remaining with the GP.
• The ANP or CNS will communicate the assessment and plan of care to GP using Vision, or in person if clinical advice or referral to specialist services via SCI Gateway is required.
• Our cluster nursing teams can admit to hospital, contact specialist clinicians for advice or escalate care to DEC@HT Consultant Geriatrician if indicated.
• The DEC@HT Consultant Geriatrician will only see people if this has been triaged as being clinically indicated by any of the nursing team.
• If accepted onto Geriatrician case load, this will be communicated to GP via Clinical Portal and a discharge letter will be issued when medical responsibility returns to GP.
• The ANP or CNS will communicate the assessment and plan of care to GP using Vision, or in person if clinical advice or referral to specialist services via SCI Gateway is required.
• Our cluster nursing teams can admit to hospital, contact specialist clinicians for advice or escalate care to DEC@HT Consultant Geriatrician if indicated.
• The DEC@HT Consultant Geriatrician will only see people if this has been triaged as being clinically indicated by any of the nursing team.
• If accepted onto Geriatrician case load, this will be communicated to GP via Clinical Portal and a discharge letter will be issued when medical responsibility returns to GP.