The Proactive Ageing Well Service (PAWS) team is part of the care group delivering proactive care in Islington and known as Frailty and Complex Care Team (FACCT). PAWS is an Islington-based, multi-disciplinary team, supporting identification of people living with moderate frailty and making an assessment to identify their health and social needs. These are predominantly around risk of falls, polypharmacy and other medicine-related issues and social isolation.

The goal is to address these needs with short-term interventions provided by the team or through onward referral and signposting to suitable services without the need for bounce back to the GP. The service aims to keep people with moderate frailty as well as possible, reduce risk of admission to hospitals or care homes for preventable causes, and maximise quality of life.

The team consists of a nurse, physiotherapist, pharmacist and Age UK navigator.

PAWS works collaboratively with Whittington Health, the Islington GP Federation, and Age UK Islington; breaking boundaries between primary, secondary care and the third sector.

The team aims to see patients at home for a holistic Comprehensive Geriatric Assessment (CGA), following this up with evidence-based interventions and signposting/referral to appropriate services in the area.

Team (on the ground):

• Dr Philly O'Riordan, GPwSI in Geriatrics
• David Lincoln, Specialist Nurse
• Ewa Grajcar, Specialist Physiotherapist
• Specialist Pharmacist - Currently recruiting
• Cynthia (Thea) Charles, Community Navigator

Wider team:

• Dr Clarissa Murdoch, Consultant Geriatrician
• Local GP Surgeries
• Age UK Islington
• Islington GP Federation

Eligibility Criteria

Inclusions

PAWs is piloting receiving referrals from services such as REACH and District Nurses. 

The service continues to work with local GPs; using their knowledge of patients, the Rockwood Frailty Index and telephone screening.

If you are a GP practice who has not yet participated and would like to, then please email the team.

How to Refer

Locations

Proactive Ageing Well Service