Frail Elderly

The aim of the Frail Elderly module is to ensure individuals at risk of hospital admission remain well in their own home.

The objective is to enhance and coordinate service provision to patients with multiple long term conditions at risk of hospital admission. A care plan is produced and enacted with patients to identify risks and goals to facilitate remaining in their own homes.

The Frail Elderly module is primarily a primary care nursing process which incorporates medical and social care with ongoing review based on the, Plan, Do, Study, Act (PDSA) cycle of care. The individual’s care plan is central to all health care contacts and interventions. The care plan is a living document for the patient, their family and their health care and social care facilitation team.

Frail Elderly


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Reviews each patient record at the start of each consultation, undertakes risk assessments such as cancer risk assessments and identifies whether a patient should be considered for particular assessments, a clinical module or a clinical referral pathway.

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Extensive range of clinical consultation support modules based on NICE adapted to local requirements for patients who have one or more clinical condition.

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Extensive range of referral pathways that are based on local standards for patient referral management.

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