FRAILTY HUB OFFERS PATIENTS ONE-STOP SHOP APPROACH TO THEIR HEALTHCARE

Frailty is characterised by individuals aged 65 or older who meet one or more of the following criteria: taking ten or more medications, living with heart failure, having two or more co-morbidities, or experiencing mild, moderate, or severe frailty.

Patients with frailty often need to see multiple healthcare professionals to address their conditions, which means attending multiple appointments in various locations. However, this can prove difficult because of their health and living in more rural areas.

What We Did

The Frailty Hub was established in September 2023 to provide coordinated care for patients with frailty and multiple long-term health conditions in Warwickshire North. 

It is designed to streamline healthcare for these individuals by offering a 'one-stop shop' approach, allowing patients to see multiple specialists during a single visit. This initiative is a collaborative project between South Warwickshire Foundation Trust, George Eliot Hospital NHS Trust, WFT, GEH, Warwickshire North Rural PCN, VCSE, and Warwickshire North Place, with the goal of addressing health inequalities and improving access to care for frail patients.

The hub also uses a Population Health Management (PHM) way of working by using data to help identify patients who may benefit from the Frailty Hub. 

One patient, a woman with frailty, and her husband attended the Frailty Hub for an assessment. During the therapy assessment, the Frailty Hub team noted that, although the patient had not experienced any falls, she showed signs of reduced balance, as identified by the Tinetti scoring system. Despite being offered a mobility aid for outdoor use, the patient initially declined it. However, she consented to a walker for her husband.

Following up with the family, the therapy team conducted a home visit to assess their needs. During this visit, the patient requested a walker after observing how beneficial it had been for her husband. The therapists also identified other equipment needs, such as a perching stool and a backrest for her bed, due to the patient's difficulty in lying flat when using a CPAP machine at night. Additionally, the patient was provided with lower limb strengthening exercises and education on managing her arthritic knee.

Outcomes

The interventions provided by the Frailty Hub have had a positive impact on the patient's care and well-being. The mobility aid, along with the equipment and exercises offered, has significantly reduced the risk of falls, promoting independence and ensuring the patient's safety. The provision of a perching stool and backrest has also improved her comfort and allowed her to manage her CPAP machine more effectively, leading to better sleep quality.

As a result, the patient has experienced improved safety, independence, and comfort, which in turn reduces the likelihood of a hospital admission.

The patient is now equipped with the necessary tools and education to manage her conditions independently, and no further interventions are planned currently.

More generally, the Frailty Hub has undertaken 667 medical reviews across six Warwickshire North practices and successfully increased patients seen in the period January to July from six to ten.

Next Steps

Looking forward, the Frailty Hub plans to expand its reach and accessibility. The team will trial clinics at Dordon & Polesworth Practice, with the aim of providing more localised services to frail patients who may have difficulty travelling. 

In addition, outreach clinics, home visits, and visits to care homes are being explored to ensure that frail patients receive the care they need in the most convenient and supportive environment possible. These initiatives aim to further reduce health inequalities and improve patient outcomes in the community.