HNY Policy and Pathway Repository - Humber

The Integrated Care Centre (ICC) will undertake a Comprehensive Geriatric Assessment of patients who are severely frail or moderately frail with at least one other referral criteria.

The ICC multidisciplinary team is inclusive of ANP/GPwER/Consultant Geriatrician/Pharmacist/Physiotherapist/Social Workers and Carers service. Patients will be seen by either a combination of these staff or the full team depending on their own individual needs/preferences.

DO NOT REFER

• Patients not currently registered within Hull GP practices
• Patients not either severely frail or moderately frail with at least one other referral criteria.

Where urgent advice/ support is required please contact the Integrated Care Centre - Frailty Support Team on 01482 247110 (Mon – Fri 8am – 6pm) to speak to a consultant or GPwER

The service will provide MDT face to face comprehensive geriatric assessment for patients identified either by their electronic frailty index score (Efi) or Clinical Frailty Score (CFS) as:

• Severely frail (eFI >0.36 or CFS 7 or above)
• Moderately frail (eFI 0.25 – 0.36 or CFS 6) AND have at least one of the following eligibility criteria:
  • Aged 90+
  • Housebound
  • Live in sheltered accommodation
  • Dementia
  • Palliative

Patients can also be referred if through practice intelligence they are identified as requiring a Comprehensive Geriatric Assessment (please provide free text clinical narrative)

Referral letter to be completed and attached via e-referral service (e-RS)

Referral form on ARDENS

• Electronic record will need to be shared with the organisation (if not already) .
• Electronic Frailty Index score to be recorded within the electronic record and included on the referral letter.
• Any additional comments to be included on the referral letter to support the service with their review process.

For patients who have been observed and assigned a frailty score by the practice, their frailty scores should be recorded within the patient’s electronic record in BOTH of the following ways: