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Nursing patients with frailty: how to create a complex needs team

Combining the skills of a frailty nurse and a GP to provide holistic care in the community

Combining the skills of a frailty nurse and a GP to provide holistic care in the community

Complex care and frailty nurse Michele Pulman: There are a lot of frail, vulnerable people out there, particularly with the COVID crisis Picture: iStock

In her new role as a complex care and frailty nurse in general practice, Michele Pulman is bringing together the skills and experience she has built up over years working in the community.

Her aim in the role is to work together with a GP to provide holistic care for the growing local cohort of patients mostly older people who have complex needs and are frail, giving them a better, more seamless service and reducing the impact on unscheduled care.

Implementing a holistic care

Combining the skills of a frailty nurse and a GP to provide holistic care in the community

Complex care and frailty nurse Michele Pulman: ‘There are a lot of frail, vulnerable people
out there, particularly with the COVID crisis’ Picture: iStock

In her new role as a complex care and frailty nurse in general practice, Michele Pulman is bringing together the skills and experience she has built up over years working in the community.

Her aim in the role is to work together with a GP to provide holistic care for the growing local cohort of patients – mostly older people – who have complex needs and are frail, giving them a better, more seamless service and reducing the impact on unscheduled care.

Implementing a holistic care plan amid a pandemic

Ms Pulman took up the post with Witley and Milford Medical Partnership in Surrey towards the end of 2019, working with GP David Triska, who has a special interest in frailty.

They were working out how to put their plan into practice when COVID-19 hit. The pandemic, and the need to support frail patients at home, gave even more impetus to the idea. It also freed up the time necessary to implement it at pace.

‘We had an idea of looking at complex care and frailty – the more proactive stuff, looking at advanced care planning,’ says Ms Pulman, who went straight into the community after qualifying in 2007, working as a district nurse and palliative care specialist.

‘It’s still developing, and we are still learning and changing things, but with COVID we’ve had more time to do that because there haven’t been as many patients in the surgery.

‘It’s given us a bit more flexibility in our ways of working, so we’ve had time to look at it.’

Assessment of potential patients for the service

Essentially, the surgery has created a dual-specialty visiting team to manage the cohort of frail and complex needs patients. The team consists of complex care nurse Ms Pulman and a GP – primarily Dr Triska – who provide proactive care for patients, using home visiting and online or telephone support.

Patients and their families have a single point of contact and Ms Pulman can bring in other services and practitioners as needed.

Patients who might benefit are identified in several ways. Ms Pulman receives discharge information daily from the local hospital and focuses on those aged over 65.

‘I look at the discharge and see what they went in with. I go into the notes, look at the medicines and at what is in place already,’ she says. ‘I do a comprehensive geriatric assessment in the community, usually with one of the doctors, so we’re looking at it from a medical and a nursing point of view. We link in with others too, such as physios, occupational therapists and community nurses.’

Analytics are also used to identify patients who might fall into the frail and complex needs category, such as those with multi-morbidity, on lots of medications, and who have frequent contact with their GP.

Remote medicine reviews are part of the holistic care approach Picture: iStock

Importance of the position during the COVID-19 pandemic

‘It’s a bit like a community matron role, but there’s more to it,’ says Ms Pulman. ‘It’s a lot of proactive care and looking at everything – so the social side of things, medication, and family support.

‘There are a lot of frail, vulnerable people out there, particularly with the COVID crisis,’ she adds. ‘They’re lonely because they can’t get social interaction, they’re not allowed to see their families. It’s important to look at the bigger picture.’

Ms Pulman, who has experience working in urban and rural, deprived and more affluent places, believes the role would work well in all types of area.

‘We’re lucky because our practice is forward thinking and keen to look at new ways of working,’ she says. ‘It will depend on individual practices whether they are keen to do it, but we are hoping to talk about it in our primary care network and try and expand it.’

Auditing effects of the service and receiving positive feedback

The practice nurse team are supportive, she says, and there are plans to expand the service to include long term conditions.

Early evidence shows the service is reducing the use of unscheduled care, which will help make the case for the new way of working.

‘We’ve done a small audit ourselves, and there’s also feedback from relatives,’ says Ms Pulman.

‘It is early days, but I was leaving a patient the other day and bumped into her daughter. She said she couldn’t thank us enough – her mother’s anxiety levels had lowered, she wasn’t calling the ambulance, and it was all since we’d been involved.’

Using digital technology for monitoring and engagement is essential

Picture: iStock

Remote monitoring using digital solutions is a big part of the role. Ms Pulman was surprised at how tech savvy many of the older patients were, with a high proportion happy to use their mobile phones.

‘I can set up a regular text message to patients, and they can reply. I do some of my follow-ups like that so I’m not actually having to go and have face-to-face consultations,’ she says.

‘We also use Ask My GP online, so patients can contact us that way. They can email us and ring in, and I can go out and follow up, but a lot of it is done digitally.

‘It saves time – but they still get that follow-up. There are loads of ways of doing this and it will get bigger. It’s exciting.’


Jennifer Trueland is a health journalist

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