Developing a MDT (Multi- Disciplinary Team) approach to meet the needs of older adults living with moderate to severe frailty in the community - Sharing of approach and insights from across Wessex
MDTs supporting older adults living with frailty in the community vary in their composition, relationships and design. One set of guidance won’t fit all; however, underlying best practice principles can be identified that lend themselves to being adopted and adapted for local needs.
This guidance was developed using the Dorset Frailty Toolkit, national best practice MDT guidance and a synthesis report by the Wessex AHSN Insight team (comprising evaluation reports on local Vanguard sites and other related projects 2016-2019 evaluating different models of integrated care). The approach was tested in Wessex on both newly developing MDT teams and already established MDT teams wanting to improve working practices.
It has been developed for health and social care professionals and those commissioning MDT services for individuals living with moderate or severe frailty in the community.
This framework has been inspired by what has worked well in Wessex. It includes:
A four step approach
How to access the toolkit
You can download the toolkit here (.zip file) or from the Resources section on this page.
Our grateful thanks to the project steering group, who reviewed and helped advise this work. Without their valuable contributions, this work would not have been possible:
Dr Laura Godfrey – GP, Weymouth and Portland Frailty Services
Annabelle Eastwood – Clinical Matron and Frailty Lead, Camrose, Gillies and Hackwood Partnership
James Lee – Nurse Consultant - Older Persons and Frailty, Salisbury NHS Foundation Trust
Vikki Altham – Service Development Officer - Adults Health and Care, Hampshire County Council
Rachel Spacagna – Care Navigator (Community & Hospital In reach), Eastleigh Southern Parishes Network
Clare Green – Care Navigator Team Lead, Eastleigh and Southern Parishes Network
Wessex AHSN project team
Dr Jackie Chandler – Evaluation Programme Manager, Wessex AHSN
Cheryl Davies – Healthy Ageing Programme Manager, Wessex AHSN
Linda du Preez – Healthy Ageing Programme Co-ordinator, Wessex AHSN.