Weymouth & Portland Frailty Service (WECS)
WECS was formed in April 2015 and provides care to both Residential and Nursing Home residents and to housebound patients living in Weymouth and Portland. The team works in an integrated way with all the GP Surgeries and with the wider multi-professional teams working in the community.
Residential and Nursing Homes
Each care home receives a weekly visit from one of the team – usually from their named clinician, but cover for leave is provided by one of the other team members. Proactive detailed and holistic assessments, chronic disease monitoring and advance care planning aim to maintain quality of life, improve symptom control and ensure personalised care is delivered. Planning for end of life care is addressed when appropriate. Dr Laura Godfrey over-sees the medical care for all Residential and Nursing home residents. Each Home has a linked GP Surgery and the relevant named clinician can be contacted via this Surgery. The team work closely with MUCS (Mobile Urgent Care Service) and they will often complete urgent visits to the care homes and with the Frailty Assistants who will often visit care home patients to complete urgent tasks.
People who are frail or becoming frail can be referred to WECS for a detailed holistic assessment which will consider all aspects of their health and care needs including social aspects, falls risk and nutritional status. This takes the form of a ‘comprehensive geriatric assessment.’ The assessment will also include identification of individual priorities for care and advance care planning to enable personalisation of care.
This is generally undertaken by one of the experienced Frailty Practitioners (Nurses or Nurse Practitioners), but complex patients will sometimes be seen by Dr Elizabeth Jones or Dr Laura Godfrey as well. The Frailty Assistants (Health care assistants) also support with some of the visits.
The aim of these proactive visits and assessments is to improve quality of life, reduce risk of deterioration, optimize medical treatment of chronic conditions, to reduce risk of admission to hospital and to enable care in the individuals own home for as long as possible thus reducing the need for admission to care homes. Referrals are made to the wider multi-professional team as needed to help support these aims.
Some patients may be discharged following the initial assessment if they are currently managing well or if they are not housebound. Patients who remain on the caseload will be visited approximately every 3-6 months (occasionally more or less) to identify any new problems, complete chronic disease monitoring and to ensure overall wellbeing is maintained.
Pandemic / lockdown changes to the service 2020/2021
Due to the pandemic, more assessments are undertaken remotely. In care homes – the weekly visit is by phone call first, followed up by video consultation and visits if needed for examination. For people living in their own home, Initial contact will be with a phone call and then the individual (or a nominated family member or friend) will be asked to fill in a questionnaire which will be posted out from the registered GP surgery – this will then be followed up by a further phone call and possibly a visit if required.