The frailty multi-disciplinary team (MDT) meeting focuses on supporting Barnet patients aged 65+. As the service commences, the frailty multi-disciplinary sessions will be split into localities, and MDT sessions will be coordinated (including admin support) by the dedicated frailty team.

The service runs one virtual MDT on a Wednesday and one virtual MDT on a Monday afternoon. The MDT will start at 2pm and finish at 4-5pm. GPs are encouraged to attend and will be given an assigned time slot to submit up to two cases. GPs are not expected to stay for the duration of the MDT.

The Frailty MDT Meetings LCS has been designed to support practices and primary care networks (PCNs) in identifying, referring and participating in the meetings. See Enhanced Services for more information.

After referral, a member of the community frailty team will conduct an initial comprehensive assessment and devise a personalised care plan. Depending on the patient's needs, they will be discussed at the assigned PCN multi-disciplinary meeting.

Core members of the MDT include:

• frailty clinical lead nurse
• frailty nurse
• 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
• Central London Community Healthcare (CLCH) planned and unplanned care services
• 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 the frailty MDT service is to provide a comprehensive borough-wide frailty service with GP practices, community providers, voluntary care sector and communities working jointly and collaboratively together across the primary and secondary care interface. This will in turn provide a holistic, proactive and preventative model to managing frailty.

It is hoped, as the model develops, that all will work together to work towards proactive identification, prevention approaches, and consideration of any areas of inequalities to ensure that the service provides care to all who need it. 

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