In Whitley Bay PCN we offer a Frailty Nurse Service that aims to support older people experiencing a decline in function, providing assessments, care planning, and potentially home visits to help them maintain independence and well-being.
What they do:
Assessment: Conduct comprehensive assessments to identify the specific needs and challenges of frail individuals.
Care Planning: Develop personalised care plans to address those needs, focusing on maintaining or improving function and well-being.
Interventions: Provide evidence based interventions, including therapy, nursing, and/or medical support (via GP or acute frailty team).
Home Visits: Offer home visits to assess individuals in their natural environment and provide ongoing support.
Discharge Planning: Support safe and appropriate discharge from hospital, if necessary.
Early Intervention and Prevention: Aim to prevent further decline in function and delay the need for more intensive care.
Referrals: Refer patients to other relevant services, such as community services, social care, or specialised teams.
Care Home Support: Provide support for older people living in care homes.
