South Ceredigion Cluster Frailty Team is providing a proactive, community-based approach which is helping people with frailty to live well independently and with greater confidence.

Approximately 10 per cent of people over 65 years have frailty, rising to 25 to 50 per cent of those aged over 85s.

For those living with frailty, even minor health issues can have to a significant long-term impact.

Since its formation in 2016, the South Ceredigion Frailty Team has taken a proactive and community-based approach to care to meet these challenges head-on.

The multidisciplinary team approach brings together nurses, pharmacists, GPs, mental health professionals and third sector coordinators.

“Our team is dedicated to ensuring that everyone - especially those living in rural areas - has access to high-quality frailty care and support”, Sarah Pask, South Ceredigion Cluster Frailty Nurse said.

“Through our community outreach strategy, we’ve been able to connect with individuals who may not regularly access GP services.

“By bringing healthcare services directly to rural communities, we’re breaking down barriers and providing essential preventative care.”

Between November 2024 and January 2025, the team completed 181 assessments.

Around 30 per cent of these were comprehensive geriatric assessments of new patients, which are in-depth evaluations used to understand a patient’s medical, functional, and social needs in order to create a personalised care plan.

The remaining 70 per cent were follow-ups to monitor progress towards goals set and review any changes to therapy.

Nearly 80 per cent of these assessments were carried out in patients’ homes, ensuring access to our services for those who may be housebound or isolated.”

Bethan Hudson, another South Ceredigion Cluster Frailty Nurse added: “During these visits we provide many services including handheld ECGs, blood pressure checks, glucose monitoring, medication management, mental health and carer support, falls prevention, and lifestyle advice such as smoking cessation and dietary guidance.

“By working closely with local GP Practices and Community Pharmacies, we ensure our outreach is fully integrated, helping to ease pressure on Primary Care while supporting patients within their community.”

The team has also built a strong presence at local events to raise awareness of their work.

This summer, they will continue attending local agricultural shows offering free health checks such as blood pressure and BMI testing to the public.

In addition to their community outreach, the team focuses on early identification and management of frailty, reducing unnecessary hospital admissions, and supporting patients in managing chronic conditions.

“The South Ceredigion Frailty Team is a fantastic example of how we can deliver care that’s not only clinically effective, but truly embedded in the communities we serve,” Jill Paterson, Director of Primary Care, Community and Long-Term Care at Hywel Dda University Health Board said.

“By reaching people where they are, building relationships, and focusing on prevention, the team is helping people to stay well, independent, and connected.

“Their long-standing dedication to frailty care embodies the Health Board’s commitment to person-centred, preventative care at the heart of the community and is making a real difference across the region.”