1. Introduction to Frailty-ACE
Frailty-ACE (Assessment and Coordination for Emergency and urgent care) is a novel and integrated approach to supporting frail people with urgent/emergency needs who would otherwise be conveyed/admitted to hospital. F-ACE is a co-located hub operating from Osprey Court, comprising Primary Care (General Practice or Severnside), Social care, and Sirona ACP expertise, supported by Consultant Geriatrician specialist input via phone.
2. Referral Process and Patient Assessment
The team receives referrals for eligible patients, either from paramedics planning to convey or via the Severnside Weekday Professional Line as an alternative to medical admission. The team's primary aim is to assess and understand the current crisis, the patient's priorities and preferences (and those of their family/carers), thereby providing holistic, person-centred care.
3. The Goal of Home-Based Care
Wherever possible, the team will aim to coordinate the services required to enable frail people to remain at home, when this aligns with their wishes and/or the balance of risks and benefits favours this approach.
4. Frailty-ACE Clinician Handbook Overview
The Frailty-ACE Clinician handbook provides an overview of the service, including tips and advice based on learning so far. It's essential to read this before your first shift, but it also serves as a reference tool for arising queries. The handbook includes an overview of the service and the team, involving patients and family/carers in making plans, F-ACE documentation, effective handovers of care, and hospital referral guidance. You can use the index to navigate directly to the content you need.
5. Clinician Resources and Tools in the Toolkit
Frailty -ACE Clinical Resources, Tools & Guidelines – BrisDoc Clinical ToolKit
Frailty-ACE clinical resources, tools, and guidelines to support F-ACE clinicians are summarised in the Toolkit. This includes useful reference resources such as the risks/harms associated with admission, the Clinical Frailty Scale, guidance about geriatric syndromes, delirium screening and causes, falls, head injuries, and prescribing/deprescribing considerations.
6. Continuous Improvement and Updates
We continually update the Toolkit, so please let us know if there is useful content we should add, ensuring the resources remain current and relevant.