Anticipatory care for our population who are living with increasing frailty risk and long-term health conditions and who are housebound or living in residential care.
Multi-disciplinary team of advanced nurse practitioners, registered nurses, and healthcare assistants, supported by frailty GP, clinical pharmacists, and care co-ordinators.
The ECT identifies those living with increasing risk who wish to remain independent at home for as long as possible but who require assessment of their changing needs, optimisation of any long-term condition, co-ordination of their care across multiple agencies and advance care planning to ensure their wishes are considered in their treatment plans.
The ECT includes a team of Nurse Practitioners and Paramedics who are trained to clinically assess those who develop acute frailty need and offer a home visiting service to those unable to attend their GP surgery. This team will provide an initial assessment and treatment on the day but also ensure there is adequate follow-up and review by the wider ECT or GP.
For the frail population with very complex needs our GPs can refer into the Frailty Lead GP, supported by a team of Advanced Nurse Practitioners and links to Consultant Geriatrician at University Hospital’s Dorset (UHD) to ensure a holistic and collaborative approach to managing their complex long-term needs.