Clinical Research Directory

Inclusion Criteria: * Referred to the CST hub from a General Practitioner (urgent referral) or from the ED at University Hospital Limerick. All of criteria 1-5 must be met 1. 75 years and over 2. Evidence of frailty, scoring between 4 and 6 on the Rockwood Clinical Frailty Scale (pre-frail, mildly frail or moderately frail) 3. Resides within CHO 3 and the catchment area of the relevant ICPOP hub 4. Patient has been assessed in-person by the referrer 5. Patient has not had MDT input within the last three months (excluding OPTIMEND team) And any one of criteria 6-10 must be met: 6. Fall within the last month unrelated to acute cardiac or neurological cause \& no previous falls assessment 7. Increased dependency or increased carer burden in the last month 8. A deterioration in swallow in the last month including symptoms of recurrent chest infections, weight loss, coughing when eating/drinking, self-modifying diet secondary to difficulties 9. Adverse drug reaction within the last month excluding allergic reaction Referred from ED/AMU following review by consultant in Emergency Medicine, Acute Medicine, Geriatric Medicine, General Medicine or Frailty at the Front Door team Exclusion Criteria: * Present with an acute neurological or cardiovascular event * Are more appropriate to an alternative care pathway or service e.g. primary care or geriatric medicine clinic * Present with injuries, unless the injury has already been appropriately managed, * Are experiencing an acute medical illness requiring treatment in an acute hospital setting * If care is being provided by other health care professionals at the time of referral and it is apparent that they are working to meet goals aligned with the current service * They require investigation or treatment not available in the relevant ICPOP hub (unless these investigations are already being arranged elsewhere) * They have had MDT input in the last three months * Have confirmed or suspected Covid-19 infection * Or other exclusions at the discretion of the integrated care team based on clinical expertise and available resource.