The Community Ageing Well Service (CAWS), formerly Frailty Multi-Disciplinary Team (MDT), supports Barnet patients aged 65+. The MDT sessions are split into localities, and coordinated by the dedicated CAWS team member.

The team meetings include a range of professionals such as GPs, acute and community healthcare staff. These are split into localities to enable collaborative case discussions that enhance the co-ordinated care of the ageing population in Barnet.

The service runs one virtual MDT meeting on a Wednesday and one on a Monday afternoon. The MDT starts 2pm and finishes at 4-5pm. GPs are encouraged to attend and are given an assigned time slot to submit up to two cases for discussion with the team or depending on capacity. GPs are not expected to stay for the duration of the MDT meeting.

The Community Ageing Well MDT's Locally Commissioned Service (LCS) supports practices and primary care networks (PCNs) in identifying patients, referring to and participating in the meetings. See Enhanced Services for more information.

After referral, a member of the Community Ageing Well Service conducts an initial comprehensive assessment and devises a personalised care plan. Depending on the patient's needs, they will be discussed at the relevant Community Ageing Well Service MDT meeting.

Core members of the MDT include:

• Clinical lead nurse
• Frailty nurses
• Geriatrician
• Psychiatrist (once per month)
• GP
• Physiotherapists
• Occupational therapists
• Age UK Nurse

Optional members as required include:

• Frailty support worker
• Palliative care team
• Voluntary services
• Dementia nurse
• Dietician
• Speech and language therapist

Two weeks prior to the MDT meeting, a member of the team will contact practices and ask for a list of patients for discussion the following week. This will allow for adequate time to schedule a visit (if required) and to invite the relevant specialities that may need to be present. 

The long-term aim of CAWS is to provide a comprehensive borough-wide frailty service with GP practices, community providers, voluntary care sector and communities working collaboratively across the primary and secondary care. This will in turn provide a holistic, proactive and preventative model for managing frailty.

Eligibility Criteria

Inclusions

• registered with a Barnet GP
• aged 65+
• eFI category of moderate/severe or CFS 5+
• within the last 12 months of life expectancy
• likely to become high-intensity unplanned care user.

Exclusions

• acutely unwell (requires rapid response or urgent care in the community).

How to Refer

Locations

Core Frailty MDT Team