The role of the practice frailty nurse
Scheme
Who?
Care Closer to Home Network
North Cumbria, North East England and Hambleton Richmondshire and Whitby on behalf of Gateshead Primary Care Services
What
A practice nurse providing care for older people living with frailty.
Why?
The role of the frailty nurse supports the area’s plan to reduce the number of frail older people who have:
- avoidable admissions to hospital
- delayed discharges from hospital.
When?
Building on the success of providing an enhanced service to care home residents, a one-year pilot was undertaken in July 2013 leading to substantive posts being introduced in 2015.
How?
The frailty nurse’s role is fundamentally to case manage older people living with complex needs and frailty. Their responsibilities include:
- undertaking comprehensive assessment and care planning
Challenges
While there weren’t any challenges during the pilot or when introducing the posts substantively, thereafter it was noted that it may prove challenging to recruit a significant number of nurses ‘ready to go’ with the same skill set
Impact
Working closely with the North of England Commissioning Support Unit and in undertaking robust clinical audits it has been identified that:
Patients managed by practice frailty nurses are admitted to
Case study
Jackie was referred to the practice frailty nurse by his GP who noted that, for the first time in more than 20 years, he hadn’t attended his annual long-term condition review appointments. Jackie, who had recently been widowed, had been categorised as