Hammersmith & Fulham care home + frailty MDT work
Lay summary
Across Hammersmith & Fulham, older patients in care homes have long been at risk of falling through gaps between primary care, community geriatric medicine, and acute hospital admission. Each transition — to A&E, into hospital, back out to a care home or supported home setting — carries risk of delirium, deconditioning, medication errors, and reduced independence afterwards. Reducing avoidable transitions, and making each one safer, is one of the most consequential things community geriatric medicine can do for this group.
Dr Wright works with the Imperial College Healthcare frailty liaison team and the borough's five Primary Care Networks on this. The collaboration is documented in three BGS-hosted artefacts: a 2020 BGS Spring Conference abstract on the care home liaison role (Sendall, Wright, Downes); a 2021 BGS Autumn Meeting case presentation with two GPs and the frailty liaison matron showing how the multidisciplinary team approach changed outcomes for specific complex care home residents; and a 2022 BGS Community Geriatrics video case presentation (hosted on the BGS resources page) that the BGS uses as a teaching example for other regions.
The work is service development, not a controlled study — outcomes are reported alongside the clinical narrative rather than as a formal evaluation.
What it is
Service-development work across Hammersmith & Fulham's five Primary Care Networks and Imperial College Healthcare's frailty liaison team. Three BGS-hosted artefacts document the work between 2020 and 2022.
Why it matters
Older care home residents face the highest risk of avoidable hospital transitions in the older population. Reducing avoidable transitions and making each one safer is among the most consequential things community geriatric medicine can do for this group.