Frail and older people single point of access

Who is it for?

• For frail and older people over 65 years old 
• Registered with a SDCCG locality GP 
• Not in need of emergency care but could benefit from urgent multi-disciplinary support
   

When referring please: 

• Provide the patient’s details
• Ensure patients meet the eligibility criteria
• Be ready to discuss the clinical and social care needs of the patient with a clinical professional
   

How to refer

Derby City

Telephone: 01332 258 258

Amber Valley & South Dales

Telephone : 01773 828 700

South Derbyshire

Telephone: 01283 818 080

 

The service is intended for frail people with syndromes associated with this such as falls, polypharmacy and reduced mobility.

This service operates in the specialist assessment and rehabilitation centre (SpARC) at London Road Community Hospital (LRCH), and is open Monday to Friday, 8.30am - 5.30pm.

Providing a geriatrician led multi-disciplinary assessment to avoid the patient getting to a crisis that may result in an attendance at the emergency department or a non-elective acute admission.

Following their assessment patients are likely to come back for a follow-up review, however on the initial assessment day, it will be determined what the patient needs in terms of managing their long-term health and social care needs safely within their own home environment. 

Onward referrals to the appropriate agencies will be made, this support may come from the Trust’s integrated community health services and/or social care.

Communication will be sent back to GPs in the form of a letter detailing the actual assessment and advice with regards to ongoing management of the patient’s needs. 

Multi-disciplinary team

The team within the rapid assessment is led by a geriatrician, and includes skilled:

• Nursing 
• Physiotherapy 
• Occupational therapy 
• Skilled therapy assistants 

To refer

GPs should refer patients through Choose & Book.

If a patient is referred to the single point of access (SPA) and would benefit from a clinical multidisciplinary assessment with a  DME consultant, they will be referred through to the rapid assessment service.  

However, it may be that the patient is already in the early stages of deterioration and should be referred from the GP surgery, through to the rapid assessment service without any need for intervention from the SPA.

It is recommended that patients are seen within two working days, however to assist patient choice appointments slots will be opened up to seven days in advance.   

The 83 beds at London Road Community Hospital (LRCH) provide a seven day inpatient step-up and step-down rehabilitation service for the frail older person.

The service is supported by local GPs with support from a geriatrician, advanced nurse practitioners, and a skilled team of qualified nursing and therapy staff.

Step-up from the home environment

There is a great emphasis to use these beds for stepping patients up from their own home setting whereby the patient requires a period of non-acute inpatient multi-disciplinary assessment and a period of rehabilitation to determine and assist their immediate & long-term needs. The primary aim is to maintain the person’s independence as long as possible. 

The average length of stay is expected to be fourteen days.

 

Step-down from acute in-patient management

For an older person overcoming an acute period of illness, they may require a period of enablement and rehabilitation within a non-acute rehabilitation setting.

The average length of stay is expected to be fourteen days. 

 

Holistic case management

Whilst the patient is being managed, the multi-disciplinary team will provide case management and in doing so will liaise with families, external agencies including social care, mental health, continuing healthcare and the voluntary sector.

The recent integration of community health services will ensure engagement is optimised to take part in the person’s onward care once they have been discharged from hospital, this may include: 

• Intermediate Care 
• Community Matron Service 
• District Nursing

How to refer

Derby City

Telephone: 01332 258 258

Amber Valley & South Dales

Telephone : 01773 828 700

South Derbyshire

Telephone: 01283 818 080