Frail & Elderly

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The CCG frailty team is continuing its work to integrate services across the borough for all frail and elderly people.

  • Add patients at high risk of unplanned admission to the practice frailty register for co-ordinated case management
  • The locality MDTs now run regularly (see below). See list for meeting locations. GPs or practice nurses encouraged to visit and discuss patients.
    • North Locality - every 4th Wed morning or lunchtime
    • West Locality - every 4th Wed morning or lunchtime
    • South Locality - every 3rd Wed lunchtime
  • All referrals to the MDT should be sent before 4pm on the Tuesday each week before the meeting to
  • Care navigators are available in practices, supporting vulnerable older people to get the right care
  • There are 4 education modules that can be completed - GP Education Frail & Elderly. Upon completion a certificate will be issued

For more information about prevention of falls please refer to the Camden Integrated Network Checklist



Audiology Assessment

Adult hearing assessment services

Benefits and Tax

Services for advice and support with benefits and taxes

Bowel Screening

Bowel cancer screening service for men and women age 60-69

Care Navigation Service

Ensuring vulnerable patients aged 60+ receive the right health and social care


Short-term support in patient's own home following a hospital stay or period of ill health

CICS - Camden Integrated Care Service

Multi-disciplinary community clinics for long-term conditions

Complex Care Case Management

Delivering effective care for people with long term conditions and those with complex health and social care needs

Complex Care Risk Stratification

GPs are required to undertake regular risk profiling and risk stratification of their patients along with providing case management for the

Dementia Services

Personalised information and signposting to people with dementia, their families and carers

Falls Diagnostic Clinics

Hospital clinics for patients who have had a fall

Falls Prevention Services

Assessments, support and rehabilitation to prevent further falls

Frailty MDT/Hub

Taking a multidisciplinary approach to assessing complex/frail patients

Henna Asian Women's Group

Promoting confidence and improve health in older Asian women and men

Home Oxygen Service / Air Liquide

Oxygen for home use

Inpatient Rehabilitation Unit

Support for patients whose physical abilities reduced through illness (e.g. stroke, fall, MSK condition)

Integrated Primary Care Teams - District Nursing

High quality nursing and rehabilitation care for complex housebound patients

Intermediate Care Services

Support focusing on physical health, therapies and rehabilitation

Lee Silverman Voice Treatment - LSVT

Voice therapy for those suffering from Parkinson's disease

Memory - Camden Integrated Care Service (CICS)

Specialist service for early assessment and intervention for memory problems

Mental Health Care of Older People (MHCOP)

Community-based service for older adults with mental illness

Occupational Therapy

Provides physically disabled/frail Camden residents with adjustments to their everyday lives

Older Persons Rapid Access Clinic - OPRAC

Urgent assessment and investigation for frail older people based at Charing Cross Hospital

Personal Health Budgets

Amount of money to support healthcare and wellbeing needs of individual


Podiatry care services

Rapid Response Team

Supporting patients managed in community but at risk of admission to hospital to remain in their home

Social & Primary Care Project

For those who need social care at the weekend

Social Services

For adults in need of social care support

Speech & Language Therapy

Community SLT for adults with complex neurological need and mental health problems

TREAT HOT Clinic at the RFH

Promote and facilitate safe discharge from A&E for complex, frail and elderly patients

Related: Frailty & complex care, Cancer, EOLC