Leaflet: South Gloucestershire Community Frailty Service – Information for Patients

Who are we?

We are a team of health and social care professionals, dedicated to improving the health and wellbeing of frail, older people who are housebound or living in a care home. We work closely with your own GP who has overall responsibility for your care.

Our team consists of:
1 GP (with a special interest in the care of older people)
1 Assistant Practitioner (specialist health care assistants)
1 Rehab Support Worker
A Physiotherapist
An Occupational Therapist
A Dietician
A Community Mental Health Nurse
A Pharmacist
A Social Work Assistant
An Administrator

Who are we?

We aim to work as a team to:

  • Minimise the impact of any health problems you may have
  • Support you in maintaining as much independence as possible
  • Work with other health and social care teams to support you in staying well.

What can I expect?

If your GP refers you to the Community Frailty Service, one of our team will contact you to arrange a home visit. During the initial assessment, we will work with you to identify any concerns you have about your health and wellbeing, as well as your goals.

With your consent, further visits can then be arranged with other members of our team. These are tailored to your needs and usually take place over the course of a few weeks.

If the Community Frailty Team is visiting your care home routinely, we will ask for your consent to review your medical records. Any concerns that you, your carers or your GP have identified can also be discussed.

Examples of help we can provide include:

  • Reviewing your medication to ensure that your medicines remain suitable for you and that we minimise the risk of unnecessary side effects.
  • Reviewing your medication to ensure that your medicines remain suitable for you and that we minimise the risk of unnecessary side effects.
  • Physiotherapy – helps to restore your mobility using techniques such as exercises and manual therapy to relieve muscle pain and stiffness.
  • Occupational Therapy to promote your independence in day to day activities such as providing a small aid to help you dress, offering practical advice on ways to reduce your risk of falls and enabling you to pursue a hobby or social interest.
  • Nutrition/dietetic advice.
  • Talking to and supporting your carers to ensure your individual needs are being met
    in the best way possible.
  • Recommending local community services which may be of interest or support.
  • Giving you the opportunity to discuss any concerns or wishes you have for your future
    care

Is there anything else I need to know?

In order to assess your needs, it will be necessary to view your medical records and to discuss your care with your GP and other health professionals. If we feel you may benefit from an assessment of your care needs by a social worker, we will discuss this with you.

If you have any questions or concerns please contact our team administrator on 01225 831404 or visit the Community Frailty Service webpage.

This leaflet can be provided in other formats and languages, please contact us for more information.

Date of creation: November 2017
Date of review: November 2019
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