Specialist Assessment for Frail and Elderly (SAFE)

SAFE service in North Lincolnshire

Safecare GP federation was commissioned by North Lincolnshire CCG in August 2018 to provide the S.A.F.E. (Specialist Assessment for Frail and Elderly) service. This is an innovative service designed to improve the health and wellbeing of North Lincolnshire’s frail and elderly residents by providing a full Comprehensive Geriatric Assessment (CGA) for all patients referred into the service.

The patient’s physical, psychological, social and environmental needs are reviewed holistically, to include a medication review which advises not only on starting medications but also stopping inappropriate or unsafe medications.

Multidisciplinary team meetings are held with Clinical Lead GP, Geriatrician, community nurses, physiotherapy, occupational therapists and social services to enable outcomes to be achieved in a coordinated manner and to encourage the sharing of information and expertise within the team. The meetings are organised by a SAFE MDT coordinator. If deemed suitable and beneficial, patients will be referred to physio and occupational therapists for reviews and treatment.

Following assessment, referrals to other specialities can also be made if appropriate, such as to social services for care package assessments, Audiology, for hearing assessments & other community referrals. If any medical investigations are required, these are highlighted to the registered General Practitioner. Our team can order some investigations such as 24-hour ECGs and Echocardiograms to support patient needs.

Care homes can directly refer all new permanent residents and any resident they feel would benefit from an assessment so that their needs are addressed rapidly and effectively. We have engaged with community matrons, CRT GPs, Virtual ward teams and FEAST team in hospital so that they can refer suitable patients to the SAFE service to help patients needs.

Why refer?

The SAFE service is delivered by a team of experienced GPs and supported by local Geriatricians. This service provides patients an opportunity to have a holistic assessment in their homes or clinic, discuss and complete advanced care plans/RESPECT forms and get support to help them with their social or mobility needs. Our clinicians understand the immense workload and time constraints faced by GP colleagues on a day-to-day basis. We also understand that GPs would welcome an opportunity to spend more time with their more vulnerable and frail patients, to ensure they receive optimal care. The SAFE service provides a tool to achieve this, allowing them to reach out to their patients who would benefit from a comprehensive, holistic assessment.

Referral Criteria

Patients in the Community who have a Clinical Frailty Scale (CFS) of 5 or above

PLUS, one or more of the below:

History of Falls
Hospital Discharge following an unplanned admission
Multiple complex problems
Patients with recent multiple visits to/ from different health agents where the GP feels a CGA would be of benefit
Use of out-of-hours service/ A&E, unplanned admissions where the GP feels a CGA would be of benefit

Exclusion Criteria

Patients already under the care of a consultant geriatrician
Patients with acute/crisis needs

Referral form

Referrals are to be made by health professionals only

Registered GP

GP practice

Name of referring clinician

Referral date

patient shared gain

Patient details

Name, address, telephone number, and NHS Number.

Has the patient or their representative given consent for the findings to be shared with the wider health and social care teams?

Yes
No
Not asked

Please gain consent prior to the referral being made. If consent has not been gained, please state the reason and who should be contacted to gain consent.

Has the patient or their representative given consent for the findings to be shared with the wider health and social care teams?

Yes
No
Not asked

When arranging the appointment who should Safecare contact? You must ensure the patient/representative has given consent if the contact is not the patient

Please provide name, address and telephone number if not the patient.

Please confirm the patient’s CFS Score, reason for referral and specific concerns to be addressed

Past medical history, repeat medication list and allergy information

A computer summary of this information is acceptable.

Known social information

e.g. functional abilities, mobility, support services.