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Undertaking an extended role in frailty

Covering what an extended role in frailty might entail and things to consider when undertaking a role in frailty.

Delivery of care

Delivery of care is achieved through:

  • Comprehensive assessments of a person’s needs including structured medication reviews, Comprehensive Geriatric Assessments (CGAs), gait and mobility assessments, advance care planning, gait reviews, and assessments of mobility and delirium
  • Multidisciplinary team working including assessments, decision-making and coordination of care
  • Effective communication and sharing of relevant information amongst teams, families and across interfaces with those involved with the person’s care
  • Using a whole person (biopsychosocial) approach
  • A person-centred care approach, keeping the person, and what they want, at the centre of every conversation. Shared decision-making is key.

Patient population

This is mainly an older population who have complex care needs or frailty or both. This patient population typically needs a greater investment of time than the general population, usually requiring comprehensive reviews and, potentially, home visits. There is also an increased risk of urgent and emergency health care need, which can risk fragmentation of care. Patients may also be located within community hospitals, or secondary care services and the GP’s knowledge of the community can add depth to their care package. In this patient population there is often a lack of planned care with emergency care predominating in the last year of life.

Setting in which the role works

A frailty GPwER may often work across various parts of the health system but can be based in a secondary care system or may be working across a geographical area where practices call on this GPwER for support as required. The Primary Care Network (PCN) Integrated frailty Team is an example of an interdisciplinary primary care team in England that provides assessment, guidance and support to individuals living in their own homes or in care homes. Typically, the GP works with Advanced Practitioners and other colleagues who are competent in performing physical health assessment with the aim of diagnosing and prescribing medications if required. There is an example on the Jurassic Coast Primary Care Network website.

A frailty GPwER may attend regular and ad hoc (in-person or remote) meetings with consultants either on their own or with patient(s) and carers. The role involves working with (or leading) frailty teams and working with community teams.

Referrals

Patients are accepted by referral from a variety of sources including GPs, secondary care, voluntary sector, community teams, and carers.

Governance

The frailty GPwER works autonomously as a GP, but governance can vary depending on the organisation delivering the service. This could be done by a local commissioning service or similar.

Services the role interfaces with

This frailty GPwER interfaces:

  • hospital/frailty service
  • social services
  • physiotherapy
  • occupational therapy
  • pharmacy
  • GP networks (e.g., clusters or PCNs)
  • primary care
  • additional roles reimbursement teams
  • secondary care
  • community teams
  • voluntary sector
  • discharge teams
  • urgent care teams
  • hospital at home teams
  • nursing home staff
  • supported living home staff

Time commitment

The time commitment for a frailty GPwER is flexible, ranging from a single session (per week) to a full-time role.

Employment arrangements

The frailty GPwER is employed by a Hospital Trust, Integrated Care Board or Primary Care Network (or equivalent in the devolved nations) or other service providers. They might also be employed by a GP Network or similar. The frailty GPwER could be a partner, a salaried GP or locum/sessional GP. Their contract will stipulate that they are a GP employed to provide frailty services.