Standard 2: Older people living with frailty experience coordinated multidisciplinary support that is responsive to changes in their life, health and care.

Standard 3: Unpaid carers and care partners are valued, supported and trained to continue providing care.

Standard 4: Older people living with frailty are supported to keep active to maintain and improve mobility, independence and function.

Standard 5: Older people living with frailty are supported to eat and drink and receive specialist input if required.

Standard 6: Older people living with frailty receive early assessment and proactive management of bladder and bowel issues.

Standard 7: Older people living with frailty are prescribed medicines which are safe, effective and person centred.

Standard 8: Older people living with frailty are empowered to live well throughout their life, maximise enjoyment and die comfortably.

Standard 9: Older people living with frailty have their mental health needs addressed.

Standard 10: Older people living with frailty who experience a sudden change in their health can access timely, coordinated and consistent support.

Standard 11: When in hospital, older people living with frailty receive safe, effective and person-centred care.

Nurses must advocate on behalf of John due to him living alone and without a 'voice' in conjunction with evidence of his rapid deterioration to adequately access health care and treatment independently and without delay (NMC code 2018, Section 14.1).

The AFS identifies a collective and seamless approach amongst working professionals to address the risks identified for John within the case study who are at risk of negative health outcomes associated with health. John faces challenges in particular falls, nutrition, urinary incontinence for John these are his specific challenges to him that professional have considered using the AFS, which has assisted mitigating adverse risks, making them person-centred (NMC 2018, Section 1.1).

-          Frailty

-          Malnutrition

-          Urinary incontinence

Monitoring and follow-up of these issues would be implemented by:

Frailty

-          Regular Screening​

- Comprehensive Geriatric Assessment (CGA) that accurately evaluates John's health and needs and updates the care plan accordingly.

- Coordinated support from a multidisciplinary team, including frequent reviews and adjustments to the care plan.

-          Promote physical activity interventions that maintain mobility and strength.

​

Malnutrition

-          Nutritional Screening that addresses John's weight loss, lack of appetite and struggles with food preparation. SPOR to Dietetic and Specialist Nutrition Services, which can provide specialist support in this specific needs.

-          Develop and update care plans detailing nutritional needs, preferences, and any dietary restrictions that cover John's individual needs.

-          Ensure good oral care to facilitate comfortable eating and drinking.

​

Urinary Incontinence

-          Conduct early and regular assessments to identify John’s bladder issues and implement measures to address his struggles.

-          Involved multidisciplinary team - incontinence nurses, specialist physiotherapists, and other relevant specialists.

-          Ensure the provision of appropriate continence products and regular reviews to adjust as needed.

-          Medication Review that could have an impact on John's bladder issues.

A Comprehensive Geriatric Assessment (CGA) is the best practice for frailty assessment and includes the majority of the previously mentioned interventions.

It is important to note that if the information obtained from the CGA is incorporated into a single integrated care plan, this can ensure that the information is available when needed and is accessible to all those involved. As the information is easily shared, this would help the collaboration within a multidisciplinary team, and this should work within national protocols. A single point of contact can coordinate referrals, movement between services or places of care, follow-up and review. This ensures that people receive the care they need from the right people at the right time.

​