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Frailty Coordination Hub ensuring people receive the right care in the right place

12 July 2021

A Frailty Coordination Hub (FCH) is successfully supporting clinicians in the community to make better decisions as to whether people with mild to severe frailty should be cared for at home or admitted to hospital.

Launched in December 2020, the hub has ensured that 388 people have avoided coming to hospital and continued to be cared for in their residence. 

The hub runs seven days a week and consists of specialist frailty clinical specialist assessors and referral coordinators who give expert advice and support to clinicians attending a person with frailty. Those clinicians using the service are from primary care, North West Ambulance Service and the community services team at University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT). 

The hub is available to all residents registered with a GP within the Morecambe Bay area who fall into the below criteria: 

  • Up to 65-years-old with a clinical frailty score (CFS) of six or above which means a person is moderately to severely frail and may need help with outdoor activities and some help with basic activities or be completely dependent for personal care 
  • Over 65-years-old with a clinical frailty score of five or above which means a person is mild to severely frail. 

Clinicians attending a person at home can ring the hub where admission avoidance is clinically appropriate or when the individual has capacity and declines a recommended admission or the individual (or their representative) wishes to remain in their permanent place of residence. The hub can also be used if the clinician wishes to avoid hospital admission but would welcome a supportive conversation or help to reach a decision and/or access support available in the community including Rapid Response. 

Dr William Lumb, Clinical Director for the Integrated Services Care Group, UHMBT, said: “The Frailty Coordination Hub is ensuring people receive the right care whether this be at their home or at their local hospital. Through the support of the hub, we are helping clinicians provide the best care for their patients.” 

Patient story: 

Janet had recently been in hospital as a result of a fall and sustained a minor lumbar abrasion. She had suffered two falls on two consecutive days without injury and was mobile when the ambulance crew arrived. She also had Clostridium difficile (C. diff) and had recently started a course of prescribed antibiotics. Janet was assessed and identified as appropriate for care in the community.  

The lead clinician was keen to keep Janet at home as she wasn't acutely unwell and her observations were stable. Plus, Janet really didn't want to go back to hospital.  

The paramedic decided to contact the FCH, for support and guidance.  

During the call, the FCH were able to access electronic patients records on EMIS and Lorenzo and adult social care's systems to review Janet's care records.  

The frailty assessors were able to identify that: 

  • Janet already had a care plan in place which was due to be reviewed by the Community Therapy Team in the next week 
  • she was known to the Intermediate Care Allocation Team (ICAT) with a review of her reablement plan of care pending.  

The Hub increased the priority for the therapy team review. ICAT was also contacted to bring forward the reablement review with a view of implementing a more substantial care plan. The paramedic was happy with the suggested next steps and the hub provided a call back within 15 minutes to confirm what had been arranged.  

Feedback from staff using the service has included: 

  • A GP from North Lancashire said: “It's brilliant. I have been so impressed by this service - how quick and easy it is to refer patients who are in the precarious zone between home and hospital. Long may this service continue. Would have admitted patient to hospital if the Frailty Coordination Hub was not available.” 
  • A community heart failure nurse for Furness said: “The Nurse I spoke to at the Frailty Hub was extremely helpful and insightful about the options available to my patient.”