Prevention and early intervention
Community providers, in partnership with social care, primary care and voluntary, community and social enterprises colleagues, have a key role to play in delivering proactive care and preventing deterioration of people living with frailty, working with these people and their families. In many cases, community providers are working collaboratively with care homes to deliver enhanced health in care homes (EHCH), as part of the EHCH model of care. This is a proactive model of care that is centred on the needs of individual people, many of whom live with frailty, their families and care home staff.
Community provider leaders also recognise their role in secondary and tertiary prevention. Secondary prevention refers to 'systematically detecting the early stages of disease and intervening before full symptoms develop' with tertiary prevention being defined as 'softening the impact of an ongoing illness of injury that has lasting effects. As such, interventions help people manage long-term, often complex health problems… in order to improve as much as possible their ability to function, their quality of life and their life expectancy'.
Given their ongoing relationships and interactions with patients, frontline staff working in community providers are well placed to support people to manage frailty in the community. They are able to identify concerns at an early stage, thus reducing the risk of deterioration and a hospital admission.
Blackpool Teaching Hospitals NHS Foundation Trust
At Blackpool Teaching Hospitals NHS Foundation Trust, the team has set up a Community Frailty Service to support patients who have at least one long term health condition, including frailty, to live well alongside their existing conditions. The service is made up of a multidisciplinary team of health professionals who, upon referral, will visit a patient to work through their plan of care, which may include providing advice, education or equipment to support them to stay well at home.
Croydon Health Services NHS Trust
Croydon Health Services NHS Trust has set up a Health Visitors for Older People (HVOP) team. The HVOP team visits people in their home and provides a supportive service to vulnerable, frail and isolated older people to help them retain their independence and prevent avoidable hospital admissions. The team is made up of health visitors, community nurses and health visitor support workers, all of whom work closely with families and carers to deliver a holistic assessment of a patients needs and provide a gateway to a variety of health and social services to promote independence. This may include falls and accident prevention, advice on benefit entitlement, health and nutrition support and bereavement support.
Harrogate and District NHS Foundation Trust
In order to support people living with frailty to stay independent in their own homes, Harrogate and District NHS Foundation Trust also has Community Care Teams which integrate district nursing and therapy to deliver long and short-term nursing interventions, rehabilitation and support the management of long term conditions. The teams provide an important role in keeping hospital admissions and readmissions to a minimum and ensure patients can stay independent in their own homes.
Virtual wards (also known as 'hospital at home') are another key way community providers, alongside wider partners across the health and care system, are supporting people with frailty who have hospital-level care needs to receive care at home and avoid an unnecessary hospital admission. Virtual wards can also be used to support people with frailty after a hospital stay. Just as in hospital, people on a virtual ward are cared for by a multidisciplinary team who can provide a range of tests and treatments including blood tests and prescribing medication.
Patients are reviewed daily by the clinical team and the 'ward round' may involve a home visit or take place through video technology. Many virtual wards use technology like apps, wearables and other medical devices, enabling clinical staff to easily check in and monitor a person's recovery. Trust leaders continue to work with patients and families, including older people and those with frailty, to ensure that the use of digital and technology is inclusive and based on informed consent and understanding.
As part of national guidance on virtual wards, all integrated care systems in England have been asked to expand virtual ward capacity, with a focus on the frailty pathway, reflecting the national ambition to deliver more care in the community. Community providers have worked hard with system partners to meet ambitious national targets to scale up capacity and usage, with 10,000 virtual wards beds created by autumn 2023, and more than 240,000 patients treated to date.
Kent Community Health NHS Foundation Trust
At Kent Community Health NHS Foundation Trust, clinicians within the community frailty team are supporting people with frailty in their own home through a frailty hospital at home virtual ward. As part of the virtual ward, care is delivered by a multi-disciplinary team who accept referrals from a range of system partners with the aim of providing an alternative to hospital care in a person’s home and in care homes. This is beneficial both for patients, who are able to receive hospital level care in a familiar setting close to family and friends, and wider system flow, by preventing the risk of unnecessary hospital admissions.
We were over the moon when we realised he could have treatment at home rather than going to hospital. The service the team provided was second to none and he was so much better when he was discharged.
Kent Community Health NHS Foundation Trust
Central London Community Healthcare NHS Trust
Central London Community Healthcare NHS Trust's Hospital at Home virtual ward services provides safe and convenient hospital-level care to people with frailty in the comfort of their own home. This supports individuals to reduce the length of their hospital stay or even avoid being admitted to hospital altogether. People on a hospital at home virtual ward are cared for by a multi-skilled team who can provide a range of tests and treatments, such as blood tests with on the spot results. They can also prescribe medication and administer medications through an intravenous drip. Patients are reviewed daily by their clinical team, which may involve a home visit or take place through video technology that enables clinical staff to easily check in and monitor their recovery.
Crisis response
Although community providers are working hard to reduce the risk of people requiring urgent care through the delivery of preventative and early intervention services, there are times when urgent and emergency care is necessary. However, this care does not always have to be delivered by an ambulance or paramedic. Across the country, community providers have been scaling up the delivery of urgent community response (UCR) services, which deliver rapid response care to patients in the community within two hours of receiving a call.
UCR services contribute to more appropriate and timely care for patients, reduce pressures on urgent and emergency care pathways, and improve patient flow through the whole health and care system. For people with frailty, UCR services play a particularly vital role in delivering the right care at the right time in the right place. For instance, people with frailty are more susceptible to falls, which are often classified as lower category ambulance calls, and can mean longer waits for a response.
Research conducted by the South East Coast Ambulance Service NHS Foundation Trust shows that for every hour spent on the floor, the probability of a conveyance to hospital increases by 10%. UCR services can therefore play a key role in delivering timely and appropriate urgent care at home for people with frailty, and reducing pressure on urgent and emergency care pathways. For people living with frailty who have engaged in advanced care planning conversations, which involves an individual agreeing how they would like to be cared for in the future, the use of UCR can be vital to ensuring they are able to receive the care that works for them. Particularly if they wish to remain in familiar surroundings close to loved ones.
Over the past few years, community providers have been accelerating the delivery of UCR services in line with national targets, with a growing number of examples of good practice demonstrating clear benefits for patients and system flow.
Birmingham Community Healthcare NHS Trust
Over the last six months Birmingham Community Healthcare NHS Trust's UCR service has seen an increase in the number of people accessing the service, with approximately 170 referrals each week, in an urban area serving about 1 million people. The trust has found that approximately half of the UCR referrals they receive come from ambulance trusts (category 3/4 calls) and in most cases relate to frail people with chronic conditions. To date, the trust has found that the majority of frail people treated by UCR teams are not admitted to hospital, supporting wider pressures and bringing value to patients.
Walsall Healthcare NHS Trust
Walsall Healthcare NHS Trust also has a well-developed UCR service which, from March 2024, will be available 24/7, going beyond the national targets around access. As well as accepting referrals from system partners such as GPs and ambulance trusts, Walsall Healthcare NHS Trust has found that district nurses and therapists are often attending someone's home to deliver a planned visit, but shifting to delivering UCR services when an urgent incident occurs. For example, a nurse may attend for a planned visit but encounter someone who requires urgent support to correct diabetic hypoglycaemia. The trust is working to capture these instances in a more consistent way to demonstrate the value and scale of the service.
Front door frailty services
Despite the important work community providers are doing to help people with frailty stay well at home, some will continue to present at A&E. According to the British Geriatrics Society, identifying frailty at the hospital front door can help trigger an early comprehensive geriatric assessment and ensure people with frailty have access to the most appropriate services quickly and, where possible, be discharged on the same day.
Evidence suggests that people over 65 who are admitted to hospital are more likely to experience long stays and delayed discharges. As well as improving the experience and outcomes for those attending hospital, front door frailty services support patient flow and alleviate pressure on the wider system.
Although front door frailty services are not consistently available across the country, there are examples of where these services have been established with clear benefits for patients and system flow.
Wye Valley NHS Trust
Wye Valley NHS Trust set up a Frailty Same Day Emergency Care unit in Hereford County Hospital in September 2023. The hospital already had a well-established front door frailty team made up of advanced clinical practitioners, but the addition of a new bedded assessment area gave the team a physical base with a more appropriate environment to assess patients. The team also benefits from the presence of a geriatrician and frailty nurses who have expertise in the care of older people and can work with patients to support independence and prevent deconditioning.
The majority of patients treated at the unit are pulled from the emergency department, with a view to optimising workflow and capacity. Around two thirds of patients are discharged, and for anyone who needs to be admitted into hospital, the team ensures they are referred to the most appropriate acute medical ward. The team also have access to community rehabilitation hospitals for relevant patients.
In the first three weeks of opening, the team saw over 150 patients on the unit and outreached to around 50 more.
The major positive of the experience is the feedback from patients and their relatives who are so grateful of being cared for in a dedicated unit.
Tameside and Glossop Integrated Care NHS Foundation Trust
In December 2022, Tameside and Glossop Integrated Care NHS Foundation Trust set up a Frailty Same Emergency Care Unit in Tameside Hospital. The unit was established with the aim of providing comprehensive assessment and care for acutely unwell patients who are 65 and over. All patients are now screened each day for frailty, and those who need it are quickly transferred for a comprehensive assessment and treatment. Where appropriate, same day community discharge is arranged to avoid an unnecessary hospital admission.
From the minute this team took over the experience felt so different. The whole team were all extremely knowledgeable, friendly and caring. My mum got expert care and was involved all the way through the process. The reason why this experience was so important was that it meant her last days were spent with a team who really cared for her, and we could not have asked for more support, not just for her but for us too.
Tameside and Glossop Integrated Care NHS Foundation Trust
The staff and doctors were outstanding in their attention to detail and high level of communication.
Tameside and Glossop Integrated Care NHS Foundation Trust
Very thorough ward and services, lovely caring and kind staff. Much needed holistic approach.
Tameside and Glossop Integrated Care NHS Foundation Trust
Intermediate care
Intermediate care is particularly important for people living with frailty. This type of support can help people with frailty access additional support on a time limited basis to prevent an unnecessary hospital admission, as well as help people to regain their independence and support them to recover at home after a hospital stay, in turn reducing the risk of readmission to hospital, and reducing pressures on hospital capacity.
To date, national policy has focused on how intermediate care can support people after a hospital stay, otherwise known as 'step-down' care.
According to NHS England's intermediate care framework (published in September 2023), step-down intermediate care is 'time-limited, short-term health and/or social care provided to adults who need support after discharge from acute inpatient settings and virtual wards to help them rehabilitate, re-able and recover'. Care is often delivered by a multi-disciplinary team made up of health and social care staff working in integrated ways to deliver more holistic, wraparound care for the benefit of patients. Alongside key partners across the health and care system, community providers have a vital role to play in delivering these services.
Coventry and Warickshire ICS
Health and social care partners across Warwickshire have been working together to improve timely access to therapeutic intermediate care services upon discharge from hospital through the establishment of a Community Recovery Service. The service commenced in April 2023 and allows more people to access rehabilitation and recovery services after a hospital stay, with the aim of reducing length of stay in acute hospitals and maximising the home first approach. The package of intermediate care is provided and paid for by the NHS (via the Better Care Fund) for up to six weeks, with individuals being encouraged to maximise the use of this time to reduce the need for further care.
As part of this programme, all patients who no longer fit the criteria to reside in hospital and are assessed as pathway 1 (this applies to someone who is ready to be discharged to a usual place of residence or temporary accommodation with some form of health and/or care and support needs), are triaged by the therapy team to decide if they need ongoing therapeutic intervention alongside a domiciliary care package. Care is delivered at a person's home by the Community Recovery Service which is made up of domiciliary care workers and allied health professionals from South Warwickshire University NHS Foundation Trust.
Walsall Healthcare NHS Trust
Walsall Healthcare NHS Trust has a well-established intermediate care service delivered by a multi-disciplinary team across Walsall Healthcare NHS Trust and Walsall adult social care. The service provides short-term, intensive support to patients to help them leave hospital as soon as it is safe to do so. The team, which is made up of a range of health and care professionals, offers support to help patients regain their independence, either at home or in a short-stay care home bed, in a way that best suits their needs.