Respond

RESPOND: Across a person’s life course, offer Universal Personalised Care (including Personalised Care and Support Planning), enabling choice, shared decision making and support based on their needs and ‘what matters to them’ including:

• Healthy ageing and caring approaches with signposting to keeping active, engaged and independent, including access to frailty-friendly living and homes.
• Community connectivity with access to and involvement of the Voluntary, Community and Social Enterprise sector.
• Specific, tailored  support for Long Term Conditions, including supportive self-management and shared decision making to develop a self-management plan (with contingency planning) optimising falls and immobility, medicine/polypharmacy and mental health.
• Access to specialist interagency teams for a comprehensive geriatric assessment [CGA] and case management including the development of an emergency health care plan to coordinate care and optimise nutrition and hydration, bowel and bladder care, vision and hearing, cognition and dementia care, and end of life.
• Access to community crisis and recovery services (with active recuperation, rehabilitation and reablement) including frailty-focused transport and timely transfers of care from hospital involving families and carers.
• Access to experts offering frailty-based care in hospital with frailty assessment, diagnostics and pathways.

For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures see Frailty Toolkit document page 43.