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Implementation of the Somerset pathway for frail older people

To identify people at risk of frailty, people with frailty and people with advanced frailty so that their needs can be fully assessed in partnership with them and their families and a personalised plan of care put in place to enable their wishes for treatment and care to be met


This project is a workforce development project led by the Somerset Clinical Commissioning Group.  It aims to improve outcomes for people with long term conditions and frail older people through integrated models of care delivery building on the work of the Symphony project in South Somerset, which is now also a Vanguard site.

This project has successfully demonstrated the people’s interactions with the health and care system are driven by the number of long-term conditions where frailty is a long term condition and that by helping people with multiple long-term conditions to understand and self-manage their conditions, and by providing more joined-up care coordination, with clear pathways in place for frail older people the pressures on the system would dramatically reduce.

Test and Learns (in three Local Implementation Groups in South Somerset, Taunton and Mendip) will implement integrated models of care delivery and implementation of the pathway for frail older people with the aim for each to see between 200 and 1000 patients or service users in the this first year of operation.

Our proposal for a workforce development project will lead to full implementation of the pathway for frail older people across all providers in health and care.

The project is aiming to be completed in September 2016.

    The project will include the following key aspects:

    1. Training and development in frailty, use of frailty screening  to identify frail older people and people at risk of frailty and the referral pathway and care planning, for domiciliary care providers who are keen to engage with this programme and in contact with a  significant group of the population that health services may not be engaged with.
    2. Training and development in frailty, use of frailty screening to identify frail older people and people at risk of frailty and the referral pathway and care planning for Age Concern peer supporters in the project in place in West Somerset / Somerset Coast (LIG) which is building on the work of the Newquay pathfinder site in Cornwall to have a guided conversation with a volunteer to agree health and care outcomes for older people.

    3. Training and development in frailty, use of frailty screening to identify frail older people and people at risk of frailty and the referral pathway and care planning for the health connectors project in the Mendip LIG that is contacting people with long term conditions in Mendip to have a conversation about their health and care needs and promote self-management and signposting to peer support networks in their local community.

    4. Expert clinical leadership and advice and support to lead implementation of the pathway across all health and care providers.

    5. We would also like to support the provision of four Master Classes for each of the LIGs in frailty and frailty screening to support implementation of the pathway in the test and learn projects in primary care.

    Anticipated benefits:

    • The benefits to individuals and to the health and care community will be in line with the Kings Fund report that found that when asked what older people value in terms of wellbeing and quality of life. 
    • The benefit will also be reduced numbers of emergency admissions to hospital for frail older people and a reduced length of stay when they do need to be admitted.

    For more information, please contact Lucy Watson, Director of Quality, Safety and Governance, and Caldicott Guardian at the Somerset Clinical Commissioning Group, Yeovil.


    This Page was last updated on: 26 November 2015

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