What We Offer

Each patient receives a standardised, person-centred assessment, covering:

• Social and functional needs
• Cognitive Screening
• Lying/standing BP checks
• Falls and bone health review
• Continence and skin assessments
• Medication review and reconciliation (supported by a dedicated Frailty Pharmacist)
• Nutritional screening
• Advanced Care Planning
• Discharge action planning

The care model supports early and safe discharge by linking with:

• Virtual Ward and Hospital at Home
• Discharge to Assess pathways
• Community teams, including GPs with special interests, community nurses
• Voluntary sector organisations such as Age UK
• Hospice at Home and community hospitals