Service overview
Frailty ACE (F-ACE) is a co-located hub which brings together experienced, senior clinical and social care professionals as a ‘team of teams’. Each individual brings not only their professional expertise but also knowledge of, and access to, the services their organisations can provide as part of a joined up, person-centred urgent care response. By working together across traditional professional, service and organisational boundaries, the ACE approach supports person-centred decision making, enables shared risk holding and supports the management of uncertainty to achieve better outcomes for individuals.
F-ACE is specifically focused on frail patients and exploring the alternatives to hospital admission for these patients who may end up with long stays that are not that person’s preference or in their best interest.
Patient flow
F-ACE patients will flow from both paramedics on scene and referrals from the Weekday Professional Line team. The F-ACE team is open to receive patients Monday to Friday 09:00-16:30 hours.
Patient referrals/criteria
Paramedic/CEMs (Community Emergency Medicine) referrals
Paramedics on scene will call ACE if the patient is likely to require conveyance or admission who meets one or more of the following criteria
- Clinical Frailty Scale ≥ 5*, or
- Dementia, or
- Aged ≥ 75 with long term condition(s)
Any clinical presentation, including
- All NEWS
- Head injuries, including on anticoagulation
- Time critical presentations (eg stroke, MI, sepsis) especially if person is very frail, likely terminal event or palliative
* 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, WDPL, SCAS and Paramedic colleagues can refer people younger than 65 to F-ACE if their functional status equates to CFS 5 or more.
Weekday Professional Line referrals
Clinicians
Weekday PL clinicians can hand patients for ACE management for patients who meet one or more of the following criteria
- Clinical Frailty Scale ≥ 5, or
- Dementia, or
- Aged ≥ 75 with long term condition(s)
If unsure, the Weekday PL can discuss with the ACE team if the patient is appropriate for handover.
System CAS referrals
System CAS (SCAS) clinician can hand patients for ACE management for patients who meet one or more of the following criteria
- Clinical Frailty Scale ≥ 5, or
- Dementia, or
- Aged ≥ 75 with long term condition(s)
If unsure, the SCAS clinician can discussed with the ACE team if the patient is appropriate for handover.
Sirona
There may be occasions when F-ACE has referred a patient to Sirona and they have a query. The Sirona team have been given the Professional Line number to recontact F-ACE within 24hours of the original F-ACE referral if needed.
Handing over of patients from Weekday PL and SCAS clinicians to F-ACE
Once the patient has been identified as suitable for ACE the Weekday Professional Line clinician will need to document all the relevant information (see separate clinical crib sheet), then forward the case in Adastra to ‘Frailty’ case type.
Out of hours
Patients should not be passed from the Out of Hours service to F-ACE. This is to reserve F-ACE capacity for Paramedic and WPL referrals.
F-ACE may refer a patient to the Out of Hours service when the GP practice is due to close, and the Out of Hours contact will support admission avoidance. To do this the F-ACE clinician will either forward the case to CC Advice Follow Up for a call back to the patient or select the ‘F2F request’ button if the patient requires a face-to-face assessment.
Mental Health Team
The Mental Health Team are available to help with input into F-ACE patients when required.
Leadership
Shift Manager
The daytime Shift Manager will be supporting the ACE team as part of Severnside in the usual.
As with current teams, the Shift Manager will provide leadership, be the first point of contact for queries and provide support as needed. The Shift Report should have any relevant information recorded that needs sharing via this route.
There will be new people in the ACE team, some who have worked at Osprey before and some who haven’t. please do introduce yourselves and explain your roles and who each team is and what they do.
We would ask that in supporting the call handling teams that the shift manager have a huddle or team talk daily, at the start of each call handlers shift, so that they can share any new information, introduce new clinical colleagues and remind the team of key points.
In addition to the operational accounts that the shift manager is asked to monitor throughout their shift, we would ask that they also have the Brisdoc.paramedic email account open. This is the account that paramedics send any information that our frailty clinicians are required to view.
Team Manager
As with any other aspect of the service the team managers and operational leads should be available to support all operational and clinical teams as needed and to share learning within the team and with Shift Managers.
Clinical Co-ordinator
The Clinical Co-ordinator (CC) is responsible for providing clinical leadership on shift. The CC on occasions may form part of the F-ACE or WPL teams if additional resilience is required. The Shift manager will need to work closely with the CC to review capacity and demand in time of pressure.
The CC can also provide additional capacity for either WPL, SCAS or F-ACE when a service is under pressure.
Systems set-up
EMIS
All primary care clinicians will have access to Severnside EMIS as usual.
The Sirona team will need to access their own EMIS platform. This has been enabled on the two allocated Sirona desks (as per seating plan). For info the organisation ID is – 28329.
On the log in page we need to ensure ‘Current connection’ is secondary, it will default to primary so we need to click on it and change to secondary.
Adastra Location
ACE-F clinicians will need Adastra open and ready on screens for log in – all should log in as location ‘Frailty ‘
Computers should be logged on using the control.room username.
Whilst SevernSide clinical teams will are able to log into Adastra with a validated smartcard, Sirona users should log in with username and password only.
Please note the social care team does not require Adastra Access
Forwarding cases
All cases when being forwarded within Adastra should have a brief summary of the request at the top of all history notes, i.e ‘Frailty case- passing to Sirona for input. Similarly, if WPL/SCAS forward to frailty, the following note should also be added ‘WPL/SCAS passing to Frailty for input’. This will allow the case to be identified by the shift manager and an additional comfort note should be added.
GP Connect
Sirona teams do not have access to GP connect, if this is required, please forward back to frailty queue for SevernSide clinician.
The Clinical Tool Kit
A page on the clinical tool kit will be provided to support the ACE-F team: Assessment and Coordination for Emergency and Urgent Care – ACE-Frailty – BrisDoc Clinical ToolKit
WI-FI Access
Please note that there is no available access to WIFI at Osprey for those joining us within the ACE-F team. If they require use of their own laptop, it should be advised that this should be done via mobile hotspot/Dongle and under no circumstances should non-BrisDoc laptops be connected to the network.
Frailty Team Phones
Phone extensions to be used by the frailty team are:
| 3107 |
| 3108 |
| 3109 |
| 3110 |
| 3111 |
| 3112 |
Take Lists
If an ACE-F clinician needs to medical admission for a patient the call handlers can add to the take list as per the WPL process. In this instance the ACE-F clinician completes the two line summary and presses ‘finish for non-clinical’. The case will land in the non-clinical queue for the call handlers to add to the take list.
Call handlers should also add “Frailty ACE -See connecting care ahead of the two line summary.
NHS@Home capacity
The Shift Manager will access the NHS@Home capacity from the UEC Dashboard and add to the whiteboards in the Pier and Concorde Rooms. Please note the UEC Dashboard is not updated until after the NHS@Home internal capacity meeting, this is usually around 9.40am.
F-ACE Escalation Plan
As part of our commitment to providing timely and effective healthcare services, this escalation plan outlines the procedures to be followed in scenarios where the Frailty ACE (F-ACE) service experiences increased pressure. The primary goal is to ensure that patient care remains a priority, and resources are strategically allocated during demanding periods.
F-ACE will accept patients from both paramedics and via the Weekday Professional Line (WPL) team without restriction. All efforts will be made to manage patient flow efficiently, maintaining the quality of care.
This escalation plan aims to provide a structured approach to managing increased pressure, ensuring that patient care remains a top priority.
Escalation
In situations where the service experiences heightened demand, an escalation decision will be implemented. The flow from the Weekday PL team will be temporarily paused to allow the service to manage the increased workload effectively. During this period, priority will be given to calls from SWAST to ensure critical cases are addressed promptly.
Criteria for Pausing Community GP Practices Intake
The decision to pause intake from the Weekday PL will be based on but not limited to the following criteria: i. High call volume and limited available resources. ii. Staffing shortages that impact service capacity. iii. Extraordinary circumstances such as public health emergencies.
The decision to pause Weekday PL referrals will be made by the Shift Manager with support of the on-call manager (covered by the Team Managers in hours) after discussion some or all the following: F-ACE team, Clinical Co-ordinator and WPL Team. The Shift Manager will ensure the decision is clearly communicated to teams on shift and recorded on the Shift Manager Report including time paused and reopened (if applicable).
During the period of increased pressure, all efforts will be directed towards prioritising and responding to paramedic calls from SWAST. Continuous monitoring will occur to assess the situation and determine when it is feasible to resume Weekday PL referrals.
During periods of pressure, it may not be possible to call paramedics back within 30 mins. On these occasions Shift Managers should ask call handlers to advise paramedics the wait time could be a bit longer.
Criteria for Pausing SWAST Paramedic calls
Extreme circumstances where the service faces challenges beyond manageable limits should be escalated by the Shift Manager to the ‘on call manager’ (this role is covered by the Team Managers in hours). The decision to close the service temporarily will require approval from the Head of Integrated Urgent Care (IUC) and/or the Urgent Care Deputy Medical Director (DMD). The Head of IUC/DMD will assess the situation in consultation with relevant stakeholders before making a closure decision.
The decision to close the service will be shared with the Shift Manager to share with the teams on shift and document on the Shift Manager Report including time paused and reopened (if applicable).
The decision will also need to be shared externally with SWAST to advise Paramedics and the DoS team to turn the service off on MiDoS.
The Shift Manager will ask the call handlers to use the following script if they receive any paramedic calls:
“I’m sorry the F-ACE Team is currently operating at full capacity and therefore are unable to take any more referrals at this time.”
Reopening the service
The decision to reopen the service will be made by the Head of IUC and/or DMD based on improved conditions and the resolution of any challenges that led to the closure.
Both SWAST and the DoS Team will need to be informed to reinstate business as usual referrals.
Review and continuous improvement
Post-incident reviews will be conducted to analyse the effectiveness of the escalation plan and identify opportunities for continuous improvement. Feedback from all stakeholders will be considered to enhance the resilience and efficiency of the service.
Tables
| Date | Version | Name | Comment |
| 28.12.2023 | 2 | Lucy Grinnell | Document create from previous F-ACE Impact test operational guidance |
| 12.01.2024 | 2.1 | Sarah Eaton | Addition of GP Connect information |
| 18.06.2024 | 2.2 | Sarah Eaton | Page 3 Change to F-ACE referral process- call handlers to send all Query Admission patients to WPL clinical team.
Pages 10 & 11 amended flow charts as above. |