Cymraeg
The Gwent Frailty Service is a multi-disciplinary, intermediate care service within the Primary Care and Community Services Division, centred on providing patients with care and/or treatment at home or as close to home as possible.
The Frailty Service is a joint provision provided by the Aneurin Bevan University Health Board and the five Gwent Local Authority Social Care Services, operating locally as a Community Resource Team.
The service aims to:
- Reduce unnecessary hospital admission by providing safe alternate pathways
- Minimise hospital stay by facilitating early hospital discharges
What is Community Resource Team (CRT)?
The Community Resource Team consists of Consultants, Doctors, Nurses, Physiotherapists, Occupational Therapists, Reablement Technicians and Support & Wellbeing Workers. The CRT provides assistance to adults (over the age of 18) living in the Gwent area who need support to stay independent, within their own home, avoiding unnecessary hospital admission.
Depending on which Borough you live, the Community Resource Team may provide the following services:
- Rapid Medical
- Rapid Nursing
- Reablement
- Falls
- Emergency Care at Home
- Social Work Assessment
- Occupational Therapy/Physiotherapy support for people in their own homes
How to access the Service?
A referral to the CRT can be submitted by a range of Healthcare professionals, processed by a dedicated team at the Single Point of Access (SPA). The SPA is the link between medical/social professionals and the Community Resource Teams (CRT).
The SPA records patient details such as demographic information/presenting condition/reason for referral and processes the referral through to the relevant locality so that care/treatment can be arranged.
The SPA will transfer the referrer through to the relevant CRT, if a clinical discussion is required to determine the most appropriate care for the patient.
Falls Prevention Service
The Falls Prevention Service provides a co-ordinated programme of assessment and interventions for elderly people who have fallen, are worried about falling or have concerns about their balance. The Falls Nurse/Therapist will ensure people referred to them receive the most appropriate, timely Multi Factorial Risk Assessment in their own home.
The Falls Team will review:
- Medication
- Continence, nutrition hydration, pain
- Balance, gait, footwear, transfers and walking
- Blood pressure lying/sitting/standing
- Osteoporosis risk factors/fracture history
- Vision, hearing, confusion, disorientation
- Environmental hazards
In some cases, people are referred to a Falls Clinic. This is a Specialist Medical Consultant led clinic which consists of:
Medical assessment and diagnostics
- Medication review
- Advanced Balance & Gait Assessment
- Onward specialist referrals
To find out more about Frailty service, please review the ABUHB Community Services internet page: Frailty – Aneurin Bevan University Health Board (nhs.wales)
