ICC Frailty Support Team - Comprehensive Geriatric Assessment - Care Home Residents

Definition/Description

The Integrated Care Centre Frailty Support Team ( ICC-FST) will undertake a Comprehensive Geriatric Assessment of permanent care home residents either newly resident to individual care homes or patients deemed complex and in need to specialist advice/support

Definition of complex ( 1 or more of following) :-

  • Behavioural issues requiring MDT approach, including those being referred for 1:1 care within the home
  • Multiple falls despite falls team intervention
  • 3 or more ED attends or admissions in past 3 months
  • 2 or more analgesics (not including paracetamol
  • Complex feeding issues or support for decision making
  • Second opinion for complex advanced care planning
  • Second opinion for diagnostic uncertainty

Red Flag Symptoms

No Red Flags Listed

Guidelines on Management

Where urgent advice/support is required please contact the ICC-FST on 01482 450078 (Mon-Fri 8am-6pm) to speak to either a consultant or GPwER in frailty.

Referral Criteria/Information

Patients MUST be registered with a either a Hull GP or East Riding GP

Permanent resident in either residential/nursing care

Electronic record sharing will need to be in place at the time of referral

Completed referral form attached to eRS. Referral forms are embedded in Ardens

Additional Resources & Reference

Electronic record sharing will need to be in place at the time of referral

Associated Policies

There are no associated policies.

Specialties

Integrated Care Centre Hull

Places covered by

  • Hull

Hospital Trusts

Author:
Date created: 03/07/2025, 14:28
Last modified: 15/07/2025, 10:58
Date of review: 02/04/2026