Specialist care for complex patients
West Kent Primary Care employee 6 General Practitioners with extended roles (GPwER)in Frailty to support the work of MDT, who look after our most frail and complex patient population. Each GP/Primary Care Network in West Kent has a multidisciplinary team meeting every two weeks to discuss new referrals from a variety of sources (GP, district nurses, social services etc). The team come together to agree an individualised plan to meet patient’s health and psychosocial needs. The aim is to proactively support complex care planning including plans for anticipated illnesses to prevent recurrent hospital admissions and identify hose that would benefit from a referral to a Consultant Geriatrician.
The Frailty GP’s will advise practice GP’s and the wider healthcare team as part of the MDT action plan and may visit individual patients and their families to discuss their care. These visits may be conducted by a Frailty GP alone or in conjunction with another member of the team, such as Complex Care Nurses.
Practices can also refer complex, frailty patients to be reviewed by our Frailty GPwER’s. The GP’s can review these patients with you jointly or make single visits, but each will be feedback to the referrer. For any questions regarding this service please e-mail email@example.com, the service is operational Tuesday – Thursday 09:00 – 17:00.
The Frailty GPwER’s are developing this service, networking with GP surgeries and the wider MDT’s to provide an effective, safe, and collaborative service to our community.
For the latest NHS advice and guidance please visit https://www.nhs.uk/conditions/coronavirus-covid-19/