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Frailty Link Worker - improving health and wellbeing in Darlington

Making a difference at Darlington Memorial Hospital, the Pioneering Care Partnership's (PCP) Frailty Link Worker, Debbie Fox, is part of a wider team of Hospital Link Workers that support patients in improving their health and wellbeing.

Debbie works with patients that are being discharged from hospital to support them in getting active, helping them through social isolation or loneliness, and can also signpost a patient into groups or services most suitable to them.

The role of a Frailty Link Worker is to engage with patients as they are discharged to ensure their health and wellbeing is prioritised when at home to prevent a return to hospital.

Meet David, Ada*, and Fred and June* (* names changed) who have kindly shared their story on how Debbie has supported them as they were discharged from hospital.

David's story

David is a 62 year old and one of the younger frailty patients admitted into hospital. After suffering a major stroke four years ago, he is regularly admitted into hospital with TIAs (mini strokes). The stroke was life changing for David, he lost most of his mobility and the impact on his mental health and wellbeing was catastrophic.

He really hit rock bottom during the Covid-19 pandemic and his quality of life drastically changed. After his most recent hospital admission he was referred to social prescribing so that we could look at ways to improve his quality of life, mental wellbeing and reduce isolation.

David was feeling depressed and low. His wife worked full time, so most of the day he was left on his own in the house with the TV for company. He was desperate to get out of the house and what mattered most for David was social inclusion and meaningful activities to give him a sense of purpose.

Prior to his stroke, David was very social and worked full time. Working together, Debbie signposted David to Bethany's Day Centre. On a Wednesday they have a few men that were attending for the same reason, so David has been attending every Wednesday since. He is really enjoying the social interaction and attending has given his wellbeing a noticeable boost. Since attending, he is also engaging with other activities and attends a group at Age UK ran by the Stroke Association. David feels having a social prescription has given him direction to know where to look for additional activities.

*Ada's story

Ada is 93 years old and was referred to the Social Prescribing Link Worker when she was admitted into Darlington Memorial Hospital in July after having a fall at home. Her nephew was keen for her to engage in the service as he was concerned about her wellbeing. Since having a fall she had become anxious and had lost all confidence and motivation. She also has Macular degeneration, which means her eyesight is very poor and is an additional anxiety for her as it makes it hard to have hobbies. Ada was once a keen reader and this is now limited due to her Macular degeneration.

Covid-19 restrictions have had a significant impact on Ada as she lives on her own, which has led to her becoming increasingly isolated and very lonely. As restrictions were in place at the time, Ada was referred into the Age UK telephone befriending service. She started getting weekly calls by a dedicated volunteer, which was a massive boost to her wellbeing as she enjoys conversation and chatting with people. Since accessing the service, she also had a procedure on her eyes that is helping her eyesight, so she has a newfound confidence and now goes shopping once a fortnight thanks to the Shildon Community Bus shopping service.

*Fred and June's story

Fred and June are in their 90’s and live in a sheltered accommodation. Fred, 96, has Parkinson’s and June, 94, has recently been diagnosed with Dementia. Due to their declining health and mobility issues, they moved out of their family home and into sheltered accommodation so that they felt closer to people and supported.

Their family live out of the area, so being close to a support system is very important to them. They were hoping that the move to sheltered accommodation would mean more social interaction as their mobility is also compromised. Sadly, they found this wasn’t the case, especially after Covid-19 hit and they found themselves becoming increasingly isolated and lonely.

Their daughter was extremely concerned for their wellbeing after Fred’s recent hospital admission due to a fall, so when offered the service by the Frailty Team she was extremely grateful and comforted to know that there an additional service available to help support and hopefully improve their quality of life.

Debbie spoke at length with the daughter and visited the couple at their home. What mattered to them both and to their daughter was having social interaction and getting out and about, but getting them both engaged has been quite difficult. Both are very anxious about leaving the home, especially with compromised mobility.

One of the main issues for Fred and June is that they are together all the time and have no respite and ran out of things to talk to each other about. In their earlier years, they were both very active, June especially. Now she felt that she was unable to go out and leave her husband alone. Debbie found that there was a local day centre, which they were not aware of that they can both attend.

Thanks to the help of their daughter, they have been persuaded to give it a try and a taster session was organised. They decided that they would attend on different days so that they have respite from each other and has given the couple a new dynamic as they both have different things they can now talk about to each other about. Their overall wellbeing is improving and giving them both a renewed purpose and focus. The daughter is so much happier and feels a little less worried and anxious about her parents, and is appreciative of the support and help she has been given.

If you would like to find out more about the work of PCP's Frailty Link Worker, Debbie Fox, contact

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