Weekday Professional Line Frailty -ACE Handover

Eligibility Criteria

The patient must meet at least one of inclusion criteria with none of the exclusion criteria

Clinical Frailty Score of 5 or above OR
Age 75 or over with long term condition(s) OR
Dementia

Exclusion criteria

Existing pathway can be accessed to support continued management at home ( eg UCR referral, own GP follow up, or hot clinic referral).
Trauma requiring X ray

F-ACE referrals can be made between 9am to 4.30pm.

Please note that we have consciously not specified age 65+ for the CFS5+ cohort. While CFS is not validated for people aged < 65, there is no established/ familiar alternative to CFS for younger patients. We know that deprivation is associated with frailty at younger ages so, to avoid excluding younger and frail patients from the ACE intervention and ensure we do not widen health inequity, people younger than 65 years can be referred to F-ACE if their functional status equates to CFS 5 or more.

Frailty ACE Key Handover information

Please log as much of the following as possible. As ever an accompanying verbal handover, if possible, will be invaluable for the receiving F-ACE team.

What are the presenting/ urgent problem(s)?
Clinical Frailty Scale (based on status two weeks prior to current illness)
NEWS and pertinent examination findings at face to face assessment
What does the patient/ family/ carer want?
Can the patient communicate on the phone? If not or difficulties, is there someone else there with them that can do so?
- Obtain the contact details for the patient/ carer/ family member
Confirm patient current address / social circumstances
- Own home/ living with family/ care home?
- What is the patients usual baseline (mobility/ ADLs)?
- What (if any) social care is already in place?
- What (if any) community services are already involved?
Is there a RESPECT form? What does it say?

Passing the CLEO case to the F-ACE team

Complete notes then select Forward, then click 'Frailty'.This will finish the WDPL case and a new Frailty case will open and be visible to the F-ACE team.Your WDPL notes will be visible as a previous encounter. Please code the Informational Outcome as 'Referred to Frailty-ACE'.

WDPL clinician advice to the referring clinician when transferring cases to F-ACE

Explain we will take ownership of the case, and liaise/ handover to the F -ACE team
We hope that the F-ACE clinician will not need to call back to the WDPL referrer but this may occasionally be required if additional information from their clinical assessment is required. It is also more likely if the WDPL team are under pressure and need to pass the case to F-ACE more quickly to maintain timely responses for new callers
If, for any reason, F-ACE cannot facilitate community management, onward referral/ transport to secondary care will be arranged by the F-ACE team without coming back to the referrer.

How will the WDPL caller know what F-ACE has done?

The practice will receive the usual WDPL post-event message (PEM) when the case is forwarded on CLEO to F-ACE. Timeframes on this being visible in EMIS depend on individual practices processes for managing this communication. The PEM is also sent to Connecting Care and should be visible in the 'Integrated Urgent Care' section within approximately 45 minutes.
Details of the F-ACE assessment and management will be available to view in a separate PEM in EMIS and Connecting Care after the F-ACE case record is closed. Sometimes F-ACE cases take several hours to close, and occasionally we will hold cases into the OOH period so the PEM may not be visible for some time.

When a F-ACE patient needs medical admission/ SDEC

The F-ACE team will write the 2 line summary on their notes and directly transfer the case to the operational team. This is preferred from an CLEO case flow perspective. However, they may seek your verbal support and advice on this process. If so, please note the usual process remains the same with the exception that the 2 two line summary makes it clear that the patient has been assessed by Frailty-ACE (as agreed with the hospital teams).

Suggested wording 'Frailty ACE, see Connecting Care'. This will serve as an alert to hospital front door teams who will aim to turn these frail patients around as quickly as possible.