The Ageing Well team is made up of highly experienced senior nurses who will support people with multiple long-term health conditions or patients with declining, moderate or severe frailty.

You may have had a number of admissions to the hospital that with some support could be prevented in the future or you are becoming increasingly frail and need additional support to recognise your symptoms and stay safe at home.

What to Expect:

A member of the team will call you to arrange a home visit and will carry out a full health needs assessment. This information will be used to create your own emergency care plan, this will help you understand and monitor your own condition and know what support is available, should it be needed. If you need to go to the hospital, the information on the plan can be shared with emergency services to help plan your treatment and care.

An emergency care plan includes things like:

How to help you spot the signs of changes in your health and what to do about it
Telephone numbers of who to contact and when
Details about your medications

The team also:

Provide information and advice on your specific health needs • Arrange tests and investigations
Review your medications
Help you self-manage your condition, plan for your future and support you to stay at home for as long as possible
Refer you to other agencies for support such as the Social Prescribing team.
Arrange for visits from other healthcare professionals such as physiotherapists or occupational therapists
If you need to go into hospital, liaise with the hospital team to ensure you can return home swiftly and safely
Work closely with your GP and other professionals involved in your care
Support you if you are becoming increasingly frail

The frequency of visits will depend on your particular needs. The team will keep you informed about visits and when they no longer need to see you, you will be given information about who to call if you need any additional support.