Frailty-ACE Clinician Handbook

1)     Welcome to Frailty-ACE

ACE – the Assessment and Coordination for Emergency and urgent care – is an integrated approach to supporting the coordination and navigation of patients’ emergency and urgent care needs focussed on improving outcomes for patients. It aims to simplify access for community-based Healthcare Professionals managing patients with urgent/ emergency needs, and is underpinned by multiprofessional and multi-organisational joint working. The overarching ACE model is inclusive of urgent care needs for people of all ages, with urgent/ emergency physical and mental health presentations.

Frailty-ACE (F-ACE) is focused on supporting the urgent/ emergency needs of frail patients who would otherwise be admitted or conveyed to hospital. 24-hour Primary Care (General Practice and Severnside) clinicians, Sirona Single Point of Access Advanced Clinical Practitioner(s) (ACPs) and a Social Worker work within the F-ACE hub, with a Consultant Geriatrician providing specialist advice by telephone when required. The F-ACE ‘team of teams’ works alongside the Severnside Weekday Professional Line (WDPL), Mental Health Integrated Access Partnership (IAP) and System Clinical Assessment Service (System CAS) teams, at BrisDoc. These clinical teams are all supported by the Severnside operational team, including the Shift manager and call handlers.

The F-ACE team provides comprehensive assessment of frail patient’s urgent care needs, including those of their carers/ family, and is person-centred, holistic and proactive in its approach. When community management is preferred and/ or in the best interests of the patient, F-ACE is able to coordinate the service(s) required to manage often complex needs at home. Those services may include any combination of Sirona Urgent Community Response (UCR), community nursing, step-up admission to the Frailty NHS@Home (virtual ward), step-up social care, frailty specialist and mental health input/ advice (via the co-located Mental Health IAP clinicians), support for carers, escalation discussions including EOL prescribing, and more. This integrated physical health, mental health and social care approach has achieved alternatives to admission for 70% of F-ACE patients, with excellent feedback from referrers, patients and F-ACE colleagues alike, and positive impact on the BNSSG Urgent and Emergency Care (UEC) system.

Thus, by working across traditional provider and service boundaries to coordinate urgent care responses tailored to individuals’ needs and with a ‘home first’ ethos, F-ACE enables a sum that is greater than the individual parts. Person-centred holistic care, trusted assessment, shared decision making, supported risk-sharing and management of uncertainty are all fundamental to this approach. The Urgent Care Integrated Governance Framework sets out the governance arrangements and principle for working safely and effectively across organisational boundaries.

2)    Frailty-ACE service

2.1       Patient referrals

Patients must meet the following criteria to be eligible for referral to the Frailty-ACE service Monday to Friday 9am-4.30pm

1. One or more of the following clinical criteria apply
   • Clinical Frailty Scale (CFS) 5, 6, 7, 8 or 9, OR
   • Dementia, OR
   • Age 75+ with long term condition(s)
2. The patient will otherwise be admitted or conveyed (i.e. if existing pathways enable management in the community these should be accessed directly e.g. hot clinics, UCR)
3. Any clinical presentation is accepted from Paramedics on scene, including
   • All NEWS
   • Time critical presentations (e.g. stroke, sepsis, MI), especially if the person is very frail, likely terminal event or palliative
   • Head injuries, including on anticoagulation
4. Trauma requiring x-ray is an exclusion criterion

F-ACE receives healthcare professional (HCP) referrals for eligible patients via two main referral routes

1. Paramedics on scene who are planning or likely to convey a frail person to hospital. Note that there one SWASFT vehicle is staffed by an ED consultant/ doctor (CEMS, Community Emergency Medicine Service), and their referrals to F-ACE are managed in the same way as paramedic crews
2. The co-located Severnside Weekday Professional Line receives calls from General Practice and Community clinicians seeking adult medical admission, and can pass cases to the co-located Frailty-ACE service as an alternative to admission.

In addition, but less commonly, HCPs working in the co-located System CAS (which manages patients who would be directed to ED or category 3/4 ambulance by NHS111) and Mental Health IAP (managing mental health dispositions arising from NHS111) may refer patients meeting the F-ACE clinical criteria.

Please note that Out of Hours patients presenting/ managed during the weekday evenings, overnight or at weekends cannot be ‘held’ to handover to the F-ACE service when it opens for referrals at 9am.

2.2      IT systems and case records

For colleagues who have not previously worked in Severnside, the Weekday Professional Line or System CAS, full support will be provided on your first shift to familiarise you with the IT systems used in F-ACE. Operational and clinical colleagues will be available for all shifts so do ask for help if you need it at any time. The main IT resources/ systems are

• CLEO – the primary clinical system for documentation of the F-ACE discussion and plan, electronic prescribing, some digital referrals etc. Online training videos are available here, plus an electronic prescribing video. F-ACE clinicians are able to initiate a video consultation from within CLEO too
• EMIS – F-ACE Primary Care clinicians will have access to the BrisDoc EMIS platform so you can view (but not write in) the longitudinal GP record, Sirona and Hospice records for the vast majority of BNSSG patients. There is a short EMIS training video for colleagues not familiar with the platform.
  • Use of the BrisDoc EMIS platform is managed in line with the Severnside EMIS policy – briefly, it must only be used for the care and management of patients being managed within the F-ACE service and must not be used to view your own records or those of friends/ family or patients you manage in other roles/ services. Colleagues may use the platform to follow up previous cases/ consultations as part of learning and professional development, usually within two months of the index clinical contact
  • Note that Sirona colleagues in F-ACE will use and access the Sirona EMIS platform – documentation on the Sirona EMIS will be in line with Sirona processes/ policies.
• Connecting Care – accessed via your BrisDoc EMIS login and the link in the menu on the left of the EMIS screen. This is particularly useful for looking at hospital records (eg discharge letters not yet visible on EMIS) and recent/ same day laboratory results. The homepage includes forthcoming appointments, and live information about whether a patient is currently in hospital/ ED
• Black Pear – we are working on enabling Frailty-ACE clinicians being able to generate/ update digital ReSPECT forms which are immediately visible in EMIS, hospital and ambulance IT systems. Before this is launched, clinicians are asked to use the ReSPECT/ DNAR processes/ template documents in place for Severnsideclinicians
• BrisDoc weblinks – quick links to a range of frequently used urgent care resources, including all of the following
  • Clinical Toolkit – clinical intranet primarily for Severnside and System CAS clinicians. There is a dedicated section for Frailty-ACE which will be kept up to date if/ when there are changes/ updates, including the latest/ live version of this handbook
  • Clinical Guardian – this is the clinical audit software. F-ACE consultations are uploaded to Guardian twice a week and a notes-based audit is undertaken by the Clinical Guardian team. Following upload of your first cases, you will receive an automated email from Clinical Guardian providing access to your account
• Call recording – all incoming and outgoing calls are automatically recorded at Osprey. This does not replace documentation. Simply dial the number you require to make an outgoing call.

The details of the F-ACE assessment, decision making and plans all need to be logged in this CLEO case record. Social care and/ or Sirona colleagues may also document in their own service/ organisation systems alongside this. The CLEO record is automatically shared as a digital Post Event Message (PEM, ‘discharge letter’) on both Connecting Care and to the practice EMIS system after the F-ACE record is closed. The PEM is visible on Connecting Care approximately 45 minutes after the case is closed, but timings for EMIS are more variable as it depends how individual practices manage these communications.

F-ACE referrals originating from the WDPL, System CAS or Mental Health IAP teams (which also operate on CLEO), are transferred digitally into the Frailty-ACE queue within CLEO. Co-location enables in-person HCP discussion/ handover between the referring clinician and F-ACE team, and this is encouraged alongside digital referral. When referring a patient to F-ACE, WDPL, System CAS and IAP colleagues are encouraged to utilise the F-ACE handover prompts. It is hoped that this will avoid/ minimise the need for the F-ACE HCP to call back the original WDPL HCP referrer again. When referred via these routes, a new ‘Frailty’ case record will be generated on CLEO. The preceding WDPL, System CAS or IAP consultation is visible via the ‘Previous encounters’ tab.

Cases originating from Paramedics on Scene are added directly to the F-ACE clinical queue by the Severnside call handler. F-ACE clinicians are encouraged to seek brief context and background on EMIS prior to calling the crew back. A key aim for the F-ACE approach is to release crews from scene as promptly as possible, so please call back as soon as possible (ideally short minutes).

General Practice and HCP callers to the WDPL seeking admission for a patient with CFS 8 or CFS 9 can be transferred directly to the F-ACE team, bypassing the WDPL team. This reflects that this cohort are severely frail/ terminally ill so will likely have complex needs but benefit least from hospital admission. In line with usual WDPL referral processes and caller experience, the call handler team will seek ‘warm transfer’ of the call to the F-ACE clinician (i.e. transfer the call directly rather than a call back to the HCP referrer). If warm transfer to a F-ACE clinician is not possible, the call will be transferred to a WDPL clinician who can then refer to F-ACE.

Irrespective of the referral source, the initial F-ACE assessment will usually be undertaken by one of the F-ACE Primary Care clinicians who will then ‘own’ the CLEO case record, ensuring it captures discussion with the patient, family/ carers, F-ACE colleagues and any other professionals, the problem list and the listed action plan. Please follow the F-ACE documentation guidance to ensure your records support handover of care and follow up after the F-ACE intervention, and the coding guidance.

3)    Your Frailty-ACE Team

The Frailty-ACE model enables real-time discussion, information sharing and coordination of one or more services to support tailored urgent care at home supported by the collective F-ACE Primary Care, urgent care, frailty, community and social care expertise. Co-location of enables real-time sense checking, advice, gathering of information and planning, and case discussion is actively encouraged. Although working remotely, the Consultant Geriatrician is very much part of the F-ACE team and available by phone for specialist clinical advice/ input when required. The F-ACE team members are integrated with community-based teams/ services outside the F-ACE hub. Supportive relationships and culture, real time conversations and effective handover are all key in enabling safe assessment, management and coordination by the F-ACE team.

The Mental Health IAP service is based upstairs at Osprey. The mental health clinicians are integrated with a wide range of mental health services and can support signposting/ referrals, as well as access the Avon & Wiltshire Mental Health Partnership clinical records (on RiO) to share background clinical information. This is particularly helpful when F-ACE is managing patients already known to dementia services and/ or with complex mental health histories. Mental health and social worker input is likely to be very helpful if there are complex capacity issues, and/ or Mental Health Act considerations.

The Clinical Coordinator (CC) GP provides a clinical leadership role, supporting WDPL, System CAS, Mental Health IAP and F-ACE teams. This may include anything from ensuring colleagues are welcomed at the start of the day, through to supporting clinical decisions and prescribing (particularly for the mental health team). The CC also has a key relationship with the operational Shift Manager, supporting decisions about capacity and flow (particularly for the System CAS, and referrals from the WDPL to F-ACE). Generally, the CC will also manage System CAS cases, but if the F-ACE team is under pressure they can pick up F-ACE cases, particularly if this will prevent referrals being declined when the service is busy or complexity is high. There will be occasions when the CC is occupying one of the Primary Care shifts within the F-ACE team. In this situation, they will be focused on F-ACE clinical work.

The operational team – comprising the Shift Manager and call handlers, supported by the operational team managers – are a vitally important part of your team. In addition to providing oversight and support for all of the services, they take calls from crews and WDPL referrers, facilitate the digital referrals when medical admission is required and can support all IT or process related queries.

3.1       Ensuring the F-ACE team works effectively

Interprofessional discussion, information-sharing and support are actively encouraged, and key to F-ACE holding risk and achieving community-based management for patents with complex, multi-faceted needs. We ask all F-ACE colleagues to proactively contribute to and seek those discussions, and to engage positively with differing views and suggestions. The social worker perspective is especially important in supporting thinking outside of the traditional health/ medical model. Lateral thinking, courageous practice and creative problem solving are encouraged in a culture of shared learning and continuous improvement. As well as EMIS and Connecting Care, additional relevant background information in the mental health and social care records can be accessed by the IAP clinicians and F-ACE social worker.

3.2      Consultant Geriatrician advice

The Consultant Geriatrician for each day is accessible by phone, as part of their NHS@Home roles. Contact details are available on the wall in the F-ACE room.

The usual contact is the ‘NHS@Home Consultant of the Day’ (name and phone numbers on the wall) for patients across BNSSG to

• Obtain clinical/ specialist advice, including diagnostic uncertainty
• Discuss referral to Frailty@Home is appropriate if more borderline or outside the Frailty@Home criteria on Remedy (note Frailty@Home referrals meeting the criteria do not have to be discussed with the Consultant, unlike in previous F-ACE trials)

If the NHS@Home Consultant of the Day is not available/ answering, contact the ‘Frailty Consultant or Frailty ACP in the NHS@Home hub’ (see spreadsheet on the wall) or the NHS@Home Point of Escalation number (07977 849960).

Contact the GALS (Geriatrician Advice and Liaison Service) consultant (numbers on the wall) if clinical/ specialist advice is required but not accessible via either of the above routes.

Based on feedback from the Consultants, please

• provide the Clinical Frailty Scale and a brief summary of the current issues/ problems/ working diagnosis(es)
• be clear about what you are seeking from their input (eg supporting diagnostic uncertainty, medication advice, options for consultant review etc)
• ensure that actions arising from Consultant input are followed up by the F-ACE hub team wherever possible (unless they can only be actioned from within secondary care)

3.3      Communication and handovers

Communication (verbal and written) are key in all of this, especially when handing over care from F-ACE to other team(s)/ service(s). As before, the CLEO records need to clearly outline a summary of the conversations/ decisions with patients, carers/ family, and professionals in the room and outside the room. The plan should be specific about suggested next steps and which teams/ services are being asked to action these. Generally, the initial F-ACE clinician will ‘own’ the CLEO record, but cases can be forwarded to others in the F-ACE team or the Mental Health team to add notes to the case record if required. If admission to hospital, or referral to SDEC or rapid access clinics, is required, this can be facilitated via the most direct pathway, avoiding ED unless there is no other option (eg trauma).

3.4      Noise/ volume in the room

Finally, F-ACE and the co-located services are often busy with colleagues consulting on the phone, as well as discussion in the room. Noise cancelling headphones are provided at all workstations, and the rooms have sound protection. However, please always be conscious to keep volumes to a minimum to avoid distraction for colleagues. If noise is problematic, do feel able to request that colleagues continue their conversation at a lower volume.

4)    Referral/ outcomes options from Frailty-ACE

As well as assessing and defining patient’s needs, ACE coordinates the service(s) required to support management at home. This may require one service, or several different services each picking up components of the care/ support the patient (and/ or their carers) require. The following services are often part of the community response

• Sirona services (coordination and referral facilitated by Sirona ACPs in F-ACE), including
  • Frailty@Home (or other BNGSSG ‘virtual ward’ pathways) – see Remedy NHS@Home information for eligibility for NHS@Home care, and information about the Frailty@Home pathway, the OPAT (iv antibiotics) pathway and Respiratory@Home pathway
  • Urgent Community Response – same day multi-disciplinary response, incorporating a comprehensive holistic assessment supporting people within the domiciliary setting who are at risk of an unplanned, hospital admission or ED attendance
  • Equipment for the home
  • Multi Factorial Falls Risk Assessment
  • Community nursing including end of life visits and fast track CHC assessment for care funding, dressings, phlebotomy
  • Other community pathways for non-emergency follow up eg, community heart failure team referral
• Primary care – urgent actions/ management to be undertaken by the F-ACE team so same day asks of general practice are unusual
  • End of life care including EOL prescribing and drug charts if not done urgently by F-ACE, supported by community nursing input +/- hospice advice if required
  • Other generalist medical input eg medication review/ suggested changes
  • Clear/ specific (non-urgent) asks of practice follow up included in F-ACE plan documented in CLEO (eg structured medication review, local MDT follow up, ReSPECT discussion)
  • Social prescribing. Carer advice.
• Social care input (coordination and referral facilitated by F-ACE social worker, or direct with care agency or Sirona UCR)
  • Step-up social care as alternative to admission if care needs are the primary driver. May include night sitting, respite, emergency package of care of same day care home placement
  • Carer assessment and advice/ support
  • Other local authority/ VCSE services eg Dementia wellbeing
• Mental health input/ follow up
  • signposting and/ or clinical input from co-located mental health clinicians from the IAP team
  • If asking for direct input from the IAP mental health team, please forward your CLEO case to the 'follow up queue' and let the shift manager know once they have been discussed with the mental health team. If required, the mental health team can forward the case back for ongoing management within the frailty team
• Referral for admission – see guidance section about medical and specialty admissions, and referring to ED
• Other – lateral thinking and creative solutions are encouraged. Examples have included fire service attendance to remove a patient’s rings or lift an acutely immobile morbidly obese person.

5)     Involving patients and family/ carers, ‘what matters to you’, shared decision making

Most of the following tips and reminders are obvious/ intuitive but all are based on learning / improvement opportunities identified from F-ACE experience and patient/ family/ carer feedback so far. We will add to these as the service continues to mature.

5.1       Consulting with healthcare professionals

The first interaction for F-ACE patients referred from Paramedics on Scene will be with the referring HCP. Take a look at the Tips and Tripwires for consulting with HCPs. For Paramedic F-ACE referrals in particular

• be supportive in your approach with the crew, recognising that their interaction with you is a learning/ development opportunity as well as focused on the patient’s needs
• support the Paramedic to undertake a more detailed/ specific examination if there are particular signs you are seeking/ want to be clear about
• consider using video if this will aid your and the crew’s decision making (recognising that video consulting may not be possible after the crew has cleared scene)
• based on previous conveyance experience, they may assume the patient requires admission and be seeking that you facilitate this, even when there may be community management options
• seek to make an early decision about whether F-ACE can take ownership of the case so the crew can handover and clear scene as promptly as possible (ideally within 30 minutes), with coordination/ follow up/ further remote assessment/ detailed discussion with the patient/ family following this. This enables the ambulance to be available for the next emergency case as soon as possible.

For cases referred to F-ACE from the WDPL team, the HCP-to-HCP conversation will usually have happened between the WDPL clinician and General Practice/ community referrer to the WDPL. The WDPL clinician will aim to obtain fuller information prior to passing the case across to F-ACE whenever their capacity allows, supported by the WDPL to F-ACE handover prompts. To improve the original WDPL referrer experience, we hope that this will avoid/ minimise the need for a second conversation and/ or call back to them because the key information is visible to you in the CLEO notes and/ or from discussion with the co-located WDPL clinician. However, if the WDPL team are under pressure, they will not have capacity to obtain full/ additional information. The General Practice communications have therefore included that it may not always be possible to avoid a second HCP to HCP (between a F-ACE clinician and the original WDPL referrer) conversation in that situation.

5.2      It is vital to explore and understand patient’s wishes, needs and priorities, and those of their carers/ families

Holistic, shared and supported decision making will require conversation with the F-ACE patient if at all possible, and if helpful, or they lack capacity regarding admission, their family/ next of kin/ Lasting Power of Attorney for Health. There may be occasions where this is not possible e.g. the patient is non-verbal, significant hearing impairment means that communication on the phone is not possible, or there is no next of kin/ family.

Focusing on ‘what matters to you’ is key to effective care and patient-centred, holistic plans in F-ACE, as is exploring ideas, concerns and expectations (ICE). This is as important as clinical red flags, symptoms and signs within your data gathering. We strongly encourage that this is undertaken before moving to discussing options and shared decision making about the next steps.

• “What Matters to You?” shifts the conversation from “what is wrong with you” to “what matters to you”. It is an international campaign that encourages and supports more conversations between people who provide health and social care and the individuals, families and carers who receive that care. Listening, dignity, compassion and respect are key, and a ‘nothing about me without me’ mindset. Explore
  • the person’s goals and the things that are important to them are discussed and form the basis of their care or treatment
  • Ask about the people that matter most in their life and have opportunity to involve them in the way that they choose
  • What information does the person need from you to support decision making?
• Some interesting blogs – NHS England ‘what matters to you’, and from the British Geriatric Society ‘What matters to the patient? Frailty, Falls and Medicines – agreeing goals of treatment.

Patient and family/ carer wishes/ views may all be aligned, or there may be differing needs, concerns, hopes, fears and expectations. Teasing this out as part of your assessment is key to achieving meaningful and supported shared decision making, and care aligned with the individual’s wishes and best interests.

Take care to support informed and shared decision making, but feel able to support and guide that decision making to ensure that family/ carers do not feel burdened with concern about the decision(s) they make or contribute to.

Decision making can be supported by the BRAN analysis (Benefits, Risks, Alternatives, Nothing). It is a decision-making tool that helps to structure thinking and the discussion when weighing up a decision, and importantly does not omit the ‘doing nothing’ option.

Listen and explicitly empathise with patient’s and carer’s/ family’s concerns, distress and fears. See specific tips/ guidance for recognising and supporting carer needs below.

5.3      Escalation/ ReSPECT plans, including palliative care

Reviewing pre-existing escalation plans/ wishes and ReSPECT documentation, and updating or creating ReSPECT documentation if required, is the norm in F-ACE. It is a key part of managing the current crisis but also planning ahead for future deterioration/ crises.

The patient’s background, the trajectory of deteriorating frailty, the nature and acuity of the current presenting crisis are important factors. Consider

• If the patient had a pre-existing care plan, has it been reviewed within the last 3 months?
• Was it written from a community or hospital perspective (eg ‘for ward based care’ suggests they were not for escalation from the ward while in hospital, but does not necessarily that they are for admission now they are in the community)?
• Have there been signs of deterioration/lack of improvement SINCE the ReSPECT was documented?
• Use the 5Ms (Mobility, Medications, Mind, Multi-complexity, Matters most) as a structured approach for identifying signs of deteriorating frailty. Examples include
  • Multiple prescriptions for antibiotics
  • Incidence of recent falls
  • > 3 admissions in the last 6 months
  • Increased contact with GP or OOH (>3 in 6months, not including meds requests)
  • Does the patient have pre-existing long term condition(s) which means that s/he is likely to deteriorate?

Recap the person’s wishes in the context of their priorities and wishes, and the balance of risks/ benefits in the context of the patient’s existing frailty, comorbidities and the current acute problem(s). Useful phrases/ tips

• Have you had previous conversations with HCPs or your family about your wishes if you became more unwell?
• What do you think is going on? What are you worried about? These sorts of questions can unlock patient’s fears/ understanding that they are dying, for example
• British Geriatric Society provides useful guidance for advanced care planning in frailty, including prognostic uncertainty
• BGS end of life considerations in urgent care is particularly relevant for the F-ACE case mix, and includes discussing uncertainty, planning for deterioration and discussing goals of care.

To create or update ReSPECT forms in F-ACE, please follow the ReSPECT guidance and download the editable forms from the Clinical Toolkit including liaising with the Shift Manager to ensure that copies are shared with the practice and SWASFT. We are working to roll out Black Pear for F-ACE clinicians, and will update you when this is in place.

It is not infrequent that the F-ACE team identifies end of life care needs for patients who are likely in the last days or weeks of life. Please ensure that EOL drug charts and electronic prescribing of just in case/ syringe driver medications are completed from F-ACE in this situation.

5.4      Going to hospital

Frailty-ACE is not seeking to block access to hospital, and approximately 25-30% of F-ACE patients will be admitted either because this is clinically required, and/ or aligns with the patient/ family’s needs/ wishes or potentially because the required community-based services do not have capacity.

• Admission is more likely to be required and the right decision if there is significant diagnostic uncertainty which makes a difference to treatments which the patient would want/ accept. Signal to the patient and family that the aim would be for discharge as soon as possible and therefore that packages of care/ meals on wheels should not be cancelled at this stage. Consider documenting your specific requests of the hospital in the CLEO notes to help tailor the hospital assessment/ management to the patient’s identified priorities, wishes and needs
• If admission is required/ agreed, always arrange/ facilitate direct referral to specialty. See admission/ referral guidance for details. Only send patients to ED if the clinical problem/ presentation requires this (e.g. trauma) and there are no alternatives. For example, a patient requiring a urology admission should be referred to urology, likewise for surgical or medical patients. Medical admissions are arranged digitally, supported by the Severnside operational team and using the same processes as the WDPL team.
• If you and the F-ACE team feels that hospital is not indicated and/ or is not in the patient’s best interests, some suggestions
  • Explore their understanding/ expectations of what hospital will achieve. Sometimes those expectations can be unrealistic (e.g. understanding that a short of breath 100+ year old F-ACE patent wanted admission for their lung to be removed enabled discussion that this was not going to happen even if he was admitted, and enabled best supportive care and a peaceful death in the care home a few days after the F-ACE interaction)
  • The concept of medical reversibility (eg treatment of pneumonia) is not the same as functional reversibility, especially when more frail at baseline, and can be helpful to tease this out
  • What has their previous hospital experience been like? Was the person functionally the same, better or worse after discharge?
  • Discuss the potential risks and benefits associated with admission. The F-ACE clinical resources/ guidance includes brief evidence/ background about risks. For example
    • hospital investigations can support diagnostic certainty, but this may be less valuable if it will not change the treatment/ management or the quantity/ quality of life
    • hospital environments are stimulating and unsettling, without familiar people/ carers
    • risk of deconditioning
    • clinical view/ consensus with F-ACE colleagues that the patient is likely in their last days/ weeks and hospital admission may well not change that
  • pressures in the UEC system in their own right should not be a factor in decision making. However, they are associated with delays in ambulances arriving, patients queuing outside hospital in ambulances, prolonged waits for beds in ED. Such delays are associated with patient harm and risks, and a difficult experience for patients and family/ carers alike. This is particularly so late at night and for the frail. If going in, is there an option to arrange this for the following morning?
  • Consider speaking with the Consultant Geriatrician to discuss what hospital would likely do/ not do. Being able to advise patients/ family/ carers that you have discussed with a consultant who supports alternatives to admission can be helpful, as can reflecting the collective expertise in the F-ACE team
  • Be aware that finances can be a factor, but this is a sensitive issue and needs tactful, careful exploration. Funding can be a particular issue if patients are coming to the end of existing funded care arrangements (eg reablement) requiring self-funding for these arrangements to continue. Hospital care can be seen as a free alternative, and patients/ families may have had experience of free care provided to facilitate timely discharge from hospital. Do utilise the expertise of the social worker, and the background information they may be able to view.
• Include ‘F-ACE – see connecting care’ in the two-line digital referral summary for medical patients. This should flag the patient as frail and complex to the hospital Transfer of Care Hub team (which supports timely discharge particularly for frail patients), so that early intervention/ front door teams can get involved early. Your case records on Connecting Care will ensure accurate and comprehensive sharing of information to support this.

5.5      Understanding and addressing carer distress, fatigue and crisis

We are working with carer groups to better understand their needs when the person they care for is in crisis, and will continue to update this section. As part of this work, a carer has said ‘I could have kissed the paramedic when they said they would take my dad to hospital. I’d been up for three nights with him and was exhausted’. So, carer crisis is often a key part of the frail person’s acute crisis/ emergency presentation, or may be the main driver for seeking hospital care. It re-emphasises the importance of talking with family/ carers and hearing their needs and distress

• Listening, acknowledgement and empathy are very important
• It can be difficult for carers/ family to express their true feelings and experience in the presence of the person they care for. Be proactive about suggesting they step away from the patient when discussing such issues
• Is/ are the informal carer(s) already recognised as such? If not, advise that they inform their own practice of their caring responsibilities, and signpost social prescriber support. If they are registered at the same practice as the F-ACE patient, you can log these as suggested follow up actions within the documented F-ACE plan. Consider signposting carer websites/ resources
• Utilise the social care expertise in the F-ACE team. Is the carer/ family (and the patient) receiving the benefits they are entitled to? Do they need a carer assessment? The F-ACE social worker may be able to view existing social care records, signpost services/ support and/ or speak with the patient/ carer as part of the F-ACE intervention
• Is the crisis caused by or creating a solely/ primarily social care need? Again, the social worker expertise and access to existing social care records will be vital in identifying step-up options if this will enable someone to remain at home. Even if this is not immediate, carers may feel that they can ‘hold on’ knowing a ‘soon’ timeframe for additional support. The Sirona ACP may be able to access night sitting support if this will enable the patient to remain at home.
• If you are concerned about the carer’s level of distress or mental health, consider involving the co-located mental health team as they may be able to speak with them to assess risk and signpost support. If this is required, a new CLEO Mental Health case record should be generated on CLEO for the carer, and the operational team will be able to facilitate this.

5.6      Understanding and supporting care staff (domiciliary, residential home and nursing home)

Paid carers will often feel anxious about continuing to support patients at home, particularly if they feel the person needs to go to hospital (or their previous experience has been that patients with similar presentations go in). Suggestions to support them include

• Exploring and addressing their ICE. This may flag, for example, that the ReSPECT form does not reflect the current plan for the patient, or concerns about difficult relationships either between staff and the patient’s family/ next of kin, or between different family members
• Specific safety netting about who and when to call back
• Consider sharing written information about the plan and safety netting advice, to support the carer and their handovers to other colleagues. The operational team can email information from the Severnside email account if required. Take care to use non-clinical language
• Providing your name and role
• Take care not to collude with either staff views of family/ carers, or family/ carer views of staff/ care provision. Instead seek to understand those views/ concerns, with particular consideration of potential safeguarding issues and the next steps.

5.7       Safeguarding

Finally, always be vigilant for potential safeguarding concerns and address/ manage risks accordingly. These are usually complex situations so the collective F-ACE experience and expertise, and particularly that of the social worker and their access to local authority background, will be invaluable.

• If safeguarding requires emergency duty team input or equivalent level of emergency input/ support, please arrange this at the time (likely via the Social worker in F-ACE). When closing the case, select ‘Yes’ and then ‘Yes’ to the two safeguarding questions that pop up. Responding ‘yes’ to the first safeguarding question will ensure that the case is reviewed as part of routine safeguarding audit (usually the following week).
• If you had active safeguarding considerations/ niggles not requiring emergency social care referral for immediate safeguarding actions, select ‘Yes’ then ‘No’ when completing the safeguarding questions. Examples might include medication errors or omissions in the care setting, or repeated inability to get through to a care home about patient care. Selecting ‘Yes’ to the first safeguarding question will ensure that the case is reviewed in the audit and supports pattern recognition eg recurrent concerns relating to specific care settings.

6)    CLEO documentation and handing over care

6.1       Documentation guidance

F-ACE notes will very likely need to be more detailed/ longer than usual General Practice/ Severnside case notes because of the complexity, family, patient and HCP involvement.

We encourage you to discuss and note as appropriate for each case:  

• Names/ roles of the people you speak to (eg Paramedic Alex) 

• Speak to the patient if possible and document if you can’t and why 

• Current ReSPECT info, brief PMH and relevant medication 

• Key salient features of the clinical history, including presence/absence of key red flags 

• Social history including home setting, baseline functional status and care package/informal care. Accurate CFS. 

• The patient’s wishes, preferences and ‘what matters to me’, and those of carers/family. If lack capacity and need a best interests decision.  

• Discussion of risks/benefits of community and hospital with patient or representative 

• Discussion about existing ReSPECT and updating to reflect current wishes and/or the patient’s best interests 

• Discussion with professionals in the F-ACE team, and any others 

• A ‘problem list’ for the urgent issues 

• An action plan to address each problem, including which service/team will action when and the actions completed by the F-ACE team. 

• Safety netting with who to contact if further concerns 

 

Note, generally one the of the F-ACE Primary Care clinicians will ‘own’ the case and CLEO record for an individual patient and can reflect others’ input in their notes. However, it may be that another clinician has been more directly involved in part of the assessment/ care and needs to add their own notes. To do this, the initial F-ACE clinician can select ‘Forward’ save and return to queue within CLEO, this will put the case back in the Frailty queue so that the second F-ACE colleague can pick it up. This can be repeated if required. Note that the Social Worker does not have access to CLEO.

If passing the case on to the Mental Health team or to Severnside Out of Hours, follow the same process and select Mental Health or CC follow up (respectively) from the list. This will close the F-ACE case and open a new Mental Health or Severnside case (reflecting that this is technically a referral to a new service).

6.2      Problem list and listed plan from the F-ACE assessment

The problem list and action plans are key to supporting effective handover of care irrespective of the patient is admitted or managed in the community. Of course, these will be specific to the patient’s presenting problems, needs and wishes. However, the following are prompts for wider things to consider as part of proactively preventing the next deterioration, including needs which cannot easily be addressed/ completed by the F-ACE team

• Services/ interventions arranged from F-ACE eg referral to UCR (and the details of what is being requested eg bloods today and follow up results, ACP visit tomorrow, review and follow up ReSPECT conversations)
• Structured medication review and deprescribing (mainly because the F-ACE team cannot edit the medication list within the practice EMIS). Please request this as an action of General Practice teams, including any specific recommendations identified thus far
• Follow up and review of the ongoing escalation plans and ReSPECT documentation. All F-ACE consultations will include discussion about resuscitation and escalation in the event of further deterioration, and the team can update the ReSPECT form if required/ agreed. However, the F-ACE team may not be able to reach a definitive documented ReSPECT plan, usually if/ when it is the first discussion patients or family have had about this. In this situation, ensure that continued ReSPECT/ escalation planning discussions thus far are documented and follow up/ completion is a requested action. If referring to UCR and/ or Frailty@Home, this is usually the most appropriate place for follow up conversations, or potentially by practice/ PCN MDTs, Community Matrons or care home leads if not.
• Requesting Multi Factorial Falls Risk Assessment (MFFRA) to assess and reduce risks of falls, usually provided by Sirona
• Follow up in practice/ PCN Multidisciplinary frailty follow up. This enables ongoing proactive care, follow up and links with local services to be facilitated. Examples might include local lunch clubs, dementia cafes, social prescribing, local activity/ exercise groups
• Requesting carer support, which might include coding family/ friends as carers and social prescriber input (if registered at the same practice as the patient)

 

Example documentation of F-ACE decision making and plans

Dw Sirona- could offer H@H if clinically indicated although I’m not convinced it is

Dw daughter- relayed above,she is clear priority is comfort and that hospital would be distressing for XXX. Wonders if this was another seizure- sounds similar to last one approx 18m ago- she has only had one since living in care home (2y) but used to have them more frequently before this. Accepts risk of further event/deterioration as we cant give definite diagnosis, but we are both in agreement to keep XXX at home under best interests

Discussed escalation if further deterioration – would prefer her care in the community wherever possible, would prefer to avoid hospital admission even if that shortens life.

PLAN

1) RESPECT form updated to reflect conversation- comfort/community care where possible

2) emailed to care home YYYY@ZZZZ.co.uk as it is friday pm and in case of further issues over weekend

3) home to escalate to 111/999 if needed over weekend- no need for H@H input

4) SWASFT to leave scene

GP ACTIONS- NON URGENT

1) GP to note updated RESPECT

2) Consider pharmacist SMR- for deprescribing medications in context of her dementia/frailty eg statin ppi ferrous sulphate

6.3      Safety netting and call backs

This is really important, both in terms of specific worrying/ red flag symptoms to watch for but also what action to take if these (or other concerns) develop. Again, it will be context specific (eg the same symptom may require different escalation if the patient is being palliative, vs someone who would be for admission if things worsened).

During F-ACE operating hours

• If the patient is concerned about worsening symptoms during ACE operating hours, it will depend where the patient has been referred. If referred to
  • UCR, their first point of contact should be the Sirona SPA (0300 125 6789, 24/7)
  • NHS@Home, the usual point of contact is the NHS@Home hub patient number (0300 125 5000, 8am-8pm 7 days a week). Outside of these hours, the usual escalation route for NHS@Home patients is to call NHS111 (or 999 for life threatening emergencies)
  • Patients can call NHS111 at any time, or their own practice (or 999 for life threatening emergencies). Patients do not have a direct call back number to Frailty-ACE (the Severnside Patient Line is not operational during the day, and is only for Severnside patients, see below).
• Healthcare professionals can call back to the Severnside Professional Line (0117 244 9283) for same day F-ACE cases to access escalation/ medical advice from the F-ACE team if there are concerns following referral from F-ACE (including if the community-based colleague thinks admission may be required)
• If community-based healthcare professionals seek medical admission for a patient who has previously been supported by the F-ACE team over the previous days/ weeks, such cases should be managed as usual by the WDPL team. However, we ask that the WDPL has a low threshold for referring back to F-ACE as an alternative to admission

Outside F-ACE operating hours (after 5pm/ evenings, weekends and overnight)

All patients can call NHS111 (or 999 for life threatening emergency) if there are concerns/ worsening symptoms, particularly during the out of hours period. In addition

• F-ACE patients referred to UCR can call the Sirona SPA, and NHS@Home patients can call the hub, as outlined above
• F-ACE patients who are passed to the Severnside OOH service (eg for evening medical review, follow up bloods etc) can also be given the OOH patient line number (for use only that evening from 6.30pm to 8am the following day)
• Patients remaining at home can contact the practice (noting that the practice will not be aware of the F-ACE intervention/ plans until after they have received the PEM/ the case has been closed on CLEO)

For Healthcare Professionals outside F-ACE hours, usual escalation processes exist within Sirona for UCR, NHS@Home and other community managed patients. This includes the option to call the Severnside Professional Line for medical advice if required.

7)     Closing F-ACE cases and accurate coding

This is especially important to ensure that we

• accurately capture the outcomes/ intended plans following the F-ACE team’s involvement, and
• identify capacity problems or gaps in service provision which prevented community management so these can be considered as part of service development.

When you select ‘Finish’ end assessment to close a case, case closure questions appear in the first pop-up window. All are mandated and most are intuitive but some specific pointers

• Safeguarding – If there were safeguarding considerations/ issues select yes (this will ensure that the case is reviewed in the weekly safeguarding audit). Select yes to the second box if those safeguarding concerns required immediate social care involvement/ referral.
• Confirm the Clinical Frailty Scale/ Rockwood – add the numerical CFS, recognising that your assessment/ scoring may differ from the referrer’s
• If the patient was admitted to hospital, select the reason why from the drop down. If community service(s) capacity was the main reason for this (ie F-ACE identified an appropriate/ reasonable plan for the patient but this could not be achieved because of lack of capacity), select all the service(s) sought but not available. This is vitally important as it helps us to define the capacity/ services required to ensure that F-ACE maximises community-based management. Please complete fully and accurately.
• If the patient was not admitted to hospital, you will also be asked if there were services you sought which did not have capacity to support the patient even though this may have been needed/ beneficial. For the same reason as before, please complete accurately
• Finally, select all the professionals involved in decision making/ providing advice about the patient’s care (both in the room and outside). We anticipate that discussion with the patient and their carer/ family will usually be yes unless there is a specific reason this has not been possible.

Select ‘Next’ once complete, and the Informational Outcomes box will appear. This is the specific code for the outcome. This is a tailored list for F-ACE patients, so please select the most appropriate single option (noting the option for multiple community-based services if more than one supported continued community management).

Continue to click through, and you will be given an option to request the Patient Liaison Service. This involves a member of the operational/ administrative team phoning the practice the following working day to alert the practice that the patient has had contact with F-ACE. Note that all F-ACE case records are shared to EMIS and to Connecting Care automatically, so the need for an additional PLS phone call will be rare/ unlikely. You will therefore usually leave the default answer as ‘No’. The specific occasions where you may select ‘Yes’ would be if the patient has died or there are active safeguarding concerns which mean that the patient will not necessarily seek advised follow up with the practice. For the latter situation, it would be preferable to use a GP Connect slot (which books the patient in for a call back usually the following day.

8)    Referring patients who need to go to hospital, including transport

8.1      Arranging digital referral for Medical SDEC and Medical Admission from F-ACE

All patients referred to the medics (for admission or SDEC) will require a short two-line summary adding to the very top of the CLEO record. The operational team will then digitally transfer this to the relevant hospital. As the F-ACE clinician is most familiar with the case, we ask that you write this for patients needing medical referral using the content guidance/ requirements below.

Generally, patients should be admitted to the hospital affiliated with their own GP surgery. Further information on what this is can be found here

Write the two-line summary at the top of the History section on the CLEO case record. Then select  the‘finish for non-clinical’  button on CLEO, and on completion of the case select 'yes' to 'NON-CLINCIAL SUPPORT TO COMPLETE CASE REQUIRED' and select the 'type required'. Please ask the clinical coordinator or weekday professional line team if unsure. This will pass the case to the Severnside operational team, who will go on to add the two-line summary to the relevant take list.

Key information to include in the 2 line summary

• Add ‘Frailty-ACE referral, see Connecting Care’ for all F-ACE patients being referred for medical admission or SDEC
• Age
• Presenting complaint/ differential
• Obs/ NEWS Score
• Relevant Past medical History
• Recent relevant treatment/ investigations
• Clinical Frailty Score/ Rockwood Score (RWS).
• Highlight any infection control concerns by adding ‘IPC+’ (acronym for infection prevention control) at the end of the 2 line summary. Please also indicate what these are in the summary ( eg D/V, CV19+). If no infection concerns, you do not need to add IPC to your summary.
• Which hospital and where the patient has been directed to (eg SDEC/ ward number/ ED). Indicate if patient is due to arrive the next day if a delayed arrival is planned
• Mode of transport to hospital (ambulance/ own transport)

Example

Frailty-ACE referral, see Connecting Care 72F, SOB/ cough 4/7.Worse despite 3/7 Doxycycline. Reduced AE left base ?effusion/ LRTI. CV19+. Pmhx: Breast Ca, HTN, T2DM. RWS6. Sats 92%, HR 101, BP 109/64, RR22, 37.7 NEWS 6. BRI A307. Own transport. IPC+

Sending medical patients to North Bristol Trust

• 32A is the main admission location for frail elderly patients. Officially this is those over 75 years AND with a CFS of 5 or more, but they also take frail over 60s if agreed with the geriatrician of the day/ AMU Consultant of the day. Do discuss with a WDPL clinician if you are unsure.
• Patients with News score 5 or above need to be directed to 31A (32A have a limited bed base to manage unstable patients)
• Patients requiring continuous monitoring (for electrolyte imbalance, cardiac arrhythmia and uncontrolled seizures) should also be directed to 31A
• NBT Medical SDEC – please see eligibility criteria and opening times here

Sending medical patients to Weston General Hospital

• All medical admissions should present to WGH ED as a medically expected patient
• If the patient is NOT arriving via ambulance, and the NEWS score is 6 or above, the Medical Registrar should be informed of their arrival in advance via bleep 219.
• WGH Medical SDEC – please see eligibility criteria and opening times
• WGH Frailty SDEC – see Frailty SDEC section

Sending medical patients to Bristol Royal Infirmary

• Most medically expected patients at the BRI should be directed to A307 (SDEC), unless they are not suitable for this location. Full details on exclusion criteria here. Note that patients must be able to sit in a chair/ recliner chair, and be able to transfer with the assistance of 1 person to be eligible
• For those not suitable for A307, please direct to BRI ED as a medically expected patient
• BRI Frailty SDEC - See Frailty SDEC section

8.2      Frailty SDEC referrals

Frailty SDEC provision is not consistently available/ funded so it may or may not be available. Currently (2026) it is available in BRI for all areas of Bristol including NBT catchment as well as South Gloucestershire and Weston. Weston also is open to F-ACE referrals into SDEC.

BRI Frailty SDEC

Based in the existing BRI SDEC setting on A306.

Opening hours: Mon-Fri 8am-6pm - last arrival by 4pm. Referrals after 12pm will be considered for next day review.

Referral Criteria:

• Frailty 5 or more
• NEWs<5
• Space for 1 non-mobile patient
• Acceptance from all areas of Bristol, South Gloucestershire and North Somerset

Exclusion: Traumatic injury (able to accept fall needing CT head just not ?#NOF etc.)

What they offer:

Frailty ANP assessment with COTE Consultant cover.
Rapid access therapy: OT, SALT, Physio.

How to refer:

Call 0117 342 8777 to discuss the case and then add to the medical take list if accepted. Or bleep 1147 via BRI switch 0117 342 1952 or 0117 923 0000. Please complete a 2 line summary as is done for admissions, documenting that they are to attend 'Frailty SDEC'.

Weston Frailty SDEC

Opening times: 9am-5pm, with last patient to be seen by 3pm for same day review.

Referral Criteria (same as for BRI Frailty SDEC):

• Frailty 5 or more
• NEWs<5
• Space for 1 non-mobile patient

Exclusion: Traumatic injury (able to accept fall needing CT head just not ?#NOF etc.)

How to refer: call 07345470496 - direct number held by either Frailty Registrar or Frailty ACP or bleep 501 via WGH switch to discuss the case and then add to the medical take list if accepted. Please complete a 2 line summary as is done for admissions, documenting that they are to attend 'Frailty SDEC'.

Weston only have one space for now in SDEC (allocated to frailty SDEC), but they are happy to discuss referrals on the bleep and see if they can see the patient the same day or early the next day.

Limited/ no Frailty SDEC capacity may well mean that admissions cannot be avoided. Please ensure that you code the F-ACE CLEO case to accurately reflected clinical need for Frailty SDEC but it not being available (both when patients go in but also when they remain at home). This will help us to quantify what capacity is needed longer term.

8.3      Rapid Access care of the elderly clinic Cossham - NBT

What does it involve?
A comprehensive geriatric assessment is performed by a consultant. Diagnostics including bloods, CAT scans and ultrasounds are preformed on the same day and a medical summary is dictated and faxed to the GP by the evening.  Medications are changed and dispensed as needed.

Which patients are eligible?

• Patients must be over 60 years old.
• Not obviously requiring acute emergency admission
• Social circumstances clear, no intractable social crises
• Deteriorating and threatening admission

Referrals should be made by telephone: 0117 340 8400 or by contacting the Consultant of the day on 07738 859048 or email referral to nbn-tr.olderpersonsrapidaccess@nhs.net

Link to webs page for NBT RACOP

8.4      Admission or SDEC referrals to other specialties

Irrespective of the original referral source to Frailty-ACE, if non-medical hospital specialty referral/ admission is required, please arrange this. Usually this will be a phone call referral to the relevant specialist team at the relevant hospital, via switchboard. Examples include General Surgery, Urology etc. This should enable patients to avoid being directed to ED unless there is a clinical requirement for this, or this is where the receiving specialty team advises that you send them.

8.5     Sending patients to ED

Emergency Department attendance/ referral should be the last resort. However, you may advise patients to attend/ be conveyed to ED if

• The receiving specialty team advises this. Ensure the F-ACE documentation clearly states that the patient is expected by the specialty team.
• Trauma is managed in ED. Examples include head injuries requiring imaging (see F-ACE head injury clinical guidance) or other trauma requiring ED investigations/ management. Trauma requiring x-ray is an exclusion criterion for paramedics to refer to F-ACE, but it is important to remember that frail patients are at risk of more significant injuries even from relatively minor mechanisms of injury. For example, the F-ACE team referred an elderly patient to ED after a fall resulted in their chest impacting the TV table. The clinical picture was concerning for more serious injury than the mechanism might suggest, and the patient was diagnosed with multiple rib fractures and significant haemothorax.
• Without causing delay for patients needing urgent ED assessment, please subsequently call the prospective ED department to refer the patient/ advise of their attendance.

8.6    Transport to hospital

The F-ACE team needs to discuss transport, and facilitate as required. See the Clinical Toolkit guidance about transport and arranging ambulances for further information. Briefly, if the F-ACE referrer is a paramedic on scene and the patient requires conveyance, arrange and confirm where the crew should convey the patient to (as outlined above).

If there is no crew on scene, explore all alternatives to an ambulance using the SWASFT guide to patient transport. Options include transport provided by the family/ carer or private taxi. If this is not possible, then the Shift Manager can arrange a taxi if this will avoid needing an ambulance. EZEC provides non-emergency, pre-bookable transport to hospital including when patients are not mobile. If the patient requires an ambulance, always make a Healthcare Professional referral to SWASFT either by telephone (0300 369 0096, or 999 if blue light/ sirens required) or digitally. Digital referral to SWASFT is made via CLEO using a module called PACCS. This requires completion of specific training to be active on your CLEO account. The Clinical Coordinators should be able to make the referral for you.

9)    Frailty-ACE – continuous learning and service improvement

An open, supportive culture of learning and improvement is core to how BrisDoc seeks to deliver and support high quality patient care and services, and colleagues. This includes learning from when things have not gone as well as any of us would want (or this was narrowly avoided), through to learning from excellence so this can be shared and celebrated.

Frailty-ACE remains in its infancy so there will be plenty of learning across all aspects of the service, including digital, clinical, operational, governance and leadership domains. Please therefore be proactive about flagging and reporting potential learning so we can review, implement improvements, feedback and share with the wider team as needed. The two main routes for this are

• Logging a learning event via the short online portal. We recommend this option particularly if learning relates to a specific case, potential concerns about patient care/ service processes, communication and handovers or (just as importantly) compliments. A learning event should certainly be reported if there are concerns about safety or potential harm, and we encourage you to discuss this with one of the clinical leads too
• Using the board in the F-ACE room to capture smaller opportunities on post-it notes. This allows real time capturing of, for example, successes, useful clinical resources/ guidance/ tools, previously unknown referral routes/ options that we can then incorporate into the service handbook.

We will be proactive about updating this guidance, and share updates by email and in the Severnside clinical newsletter. We can also come together at a case-based F-ACE Clinical Forum to review cases and learning together. At the moment, we do not have F-ACE forums planned, but will do so if there is an appetite from the team.

Resources intended to signpost you to usual local and national guidance, as well as background information about admissions and urgent/ emergency care can be found via the link below.

HERE