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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