A holistic framework used in geriatric care: Mind, Mobility, Medication, Multicomplexity, Matters Most.

Used to refer to older people whose frailty has progressed to a moderate or severe stage.

Defined as communities that actively work together to provide social, emotional and practical support.

Defined as a wider social network around the older person. This can be close relatives, but also friends, neighbours and community connections.

Defined as a space, not a place.

Defined as a state of interconnection with others, based on connectedness, mutuality and reciprocity.

Defined as the possibility of multiple different outcomes.

Defined as an approach to care  that engages assessment over time, but does not always require changes to intervention.

Care Provision

Level 2 

Interactions between the older person and their family,
and the setting where care is provided

Working together: a way of working which puts older people at the centre of what we do
Multi-disciplinary working across health settings and services
Multi-sector working, including the vital role of the voluntary sector and compassionate communities

An awareness of your community needs
An understanding of referrals in and out of your service
Using a named contact approach
Access to resources at crisis points: e.g., out of hours, intermediate care beds
Access to services which support holistic care: clinical, psychological, practical, social and spiritual needs
Enhanced access to services to provide practical support: e.g. access to rehab; staying connected with people and places, etc.