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Primary Care-led Frailty Team

A Primary Care Frailty Team based at University Hospital Coventry and Warwickshire (UHCW) has been created as part of the ongoing work of the Coventry and Rugby GP Alliance (CRGPA).

The scheme is designed to increase the capability of primary care to offer comprehensive management of frail, elderly patients and to do so from both an acute and community setting.

Supporting frail elderly patients to exit hospital with a comprehensive care plan will be the team’s main focus where they will use primary care skills in managing risk and providing cost effective diagnosis.

The scheme will establish a pathway for holistic planning and discharge for complex, frail patients with community follow-up care.

It also aims to overcome the barriers which prevent frail patients from getting a timely, safe discharge from the hospital and to prevent them from getting readmitted by supporting them in their home environment.

The scheme has been designed around patients and carers and a future patient journey has been mapped to identify the key changes that a patient will experience when they navigate through this scheme. This will act as an aide memoire for the Primary Care Frailty Team and CRGPA to ensure patients are getting the best service from the scheme.