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Referring to the Frailty Prevention Team

Our team receive referrals from GPs, the James Paget University Hospital, social services and from other services within ECCH, via our referral form. It is important to fill out as much information as possible to help us provide the best care.




Persons over 65 years old presenting with a Rockwood Assessment score of 6.

Potential additional presentation may include:

  • Falls
  • Immobility
  • Altered cognition
  • Incontinence
  • Long-term side effects of medication
  • Persons approaching palliative care
  • Complex patients who will benefit from specialist frailty intervention


  • Persons presenting with a Rockwood Assessment score of 5 or less, or 7 to 9
  • Those living with a treatable acute illness
  • Those where alcohol or drug use is the primary problem

Things to consider before referring:

  • Please score their Rockwood Assessment according to how the patient was presenting and functioning 2 weeks prior to the referral. 

  • Patients that are acutely unwell and need immediate assessment should be referred via ECCA – 01493 879977. Open Monday to Sunday (including bank holidays) 7.00am to 8.00pm

  • Please note that if a patient needs to be seen as a priority please indicate this on the referral form stating reason/s why

  • Please note that we are not an urgent rapid response service. We aim to see high priority patients within 2 to 4 working days and lower priority patients within 1 to 2 weeks.

  • Our service operates Monday to Friday 08:30 – 16:30 (excluding bank holidays)


The below referral pathway highlights how the Rockwood score helps to shape which services patients receive from different parts of East Coast Community Healthcare – those with a moderate score for frailty are supported by our team.  

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