By working in partnership with other healthcare providers, hospices can help identify and support more patients living with frailty. They can also benefit the wider health system through providing co-ordinated care and reducing hospital admissions.
On this page we're sharing what we've learnt about the benefits of having a co-ordinated approach to frailty care.
Developing a co-ordinated approach to frailty care can help make sure more patients get the support that meets their specific needs and preferences, when they need it. It creates an easier patient journey and can reduce emergency hospital admissions.
The hospices participating in our Extending Frailty Care programme found that working in partnership with other healthcare organisations had a range of benefits. You can find out more about these below.
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“Frailty is too big an agenda for any one organisation.
With financial pressures on hospice care, it may be that hospices seek to work more collaboratively with other healthcare providers and community organisations to deliver preventative measures, focusing on their areas of expertise.”
Isabel Hospice
Hospices taking part in the Extending Frailty Care Programme found that NHS partners, care homes and other community agencies became more engaged with supporting older people with frailty when they worked together in a coordinated way.
Isabel Hospice initially focused on identifying frailty and supporting patients that were already known to the hospice, before promoting its education sessions to the general public via GPs, social prescribers and other partners.
The hospice ran training three times over the course of a year and found that it improved links between the providers, and helped develop a network within the community to better support people with frailty.
For patients, this joined-up support from different providers helped to give them a greater understanding of frailty and its risks, helping them to maintain their independence at home.
Professionals from a range of organisations including primary care, secondary care, community care and social care play important roles in supporting people living with frailty. Raising awareness among these services is a vital part of making sure that individuals receive the care they need in their preferred environment.
Enabling people to access coordinated, proactive care as they need it helps reduce hospital admissions among people living with frailty.
Highland Hospice has implemented a responsive 24-hour care model, working in partnership with local domiciliary and residential care services to manage patients who are deteriorating rapidly. This ensures patients receive the medical intervention they need without being moved from the care setting that they have chosen.
Coordinating efforts between hospices and other healthcare providers can ensure a smoother transition between services, preventing gaps in care for patients whose health condition changes suddenly.
Reducing the number of ‘touch points’ patients and carers need to navigate can reduce delays to care and help them understand what services are available in the community.
As part of the Extending Frailty Care programme, St Michael's Hospice employed a care coordinator, who acts as a single point of contact for patients. They can connect patients with all the appropriate services.
Volunteers and compassionate communities play a vital role in supporting people with advancing frailty. They can offer practical and emotional support, help combat loneliness, and help individuals maintain independence at home, through engagement with social clubs and other local services.
When run in partnership with local organisations, for instance employers, faith groups, and volunteer organisations, these can help to extend the reach of hospice care and raise awareness of available services.
As part of our Extending Frailty Care Programme, a number of hospices offered frailty-focused training and support to other healthcare providers such as care homes. In doing so, they developed stronger connections with community-based teams and volunteer hubs, enhancing support for everyone in the local community.
St Christopher's Hospice worked with local residential homes, GPs, pharmacists and other local services to promote engagement with palliative care and living well. As well as improving other healthcare professionals' knowledge and awareness about frailty, the project helped everyone involved learn more about each other's role and service offer. This helped them develop a greater understanding of how they can work together across the board.
How frailty affects someone can be heavily influenced by social and demographic factors. Hospices are increasingly able to reach out to underserved groups and reduce barriers to care.
Strathcarron Hospice, for example, developed a project to help care for individuals affected by frailty in a men’s prison. Working in the prison, the hospice:
selected a specific screening tool (the Edmonton Frail Scale) to help identify frailty among the prison population
developed a prison-specific needs assessment tool to assess the holistic needs of people identified as moderately or severely frail.
They established forums and focus groups with NHS healthcare staff, carers from social care agencies and peer carers (fellow prisoners trained to support those living with frailty). This aproach ensured that all stakeholders contributed to an individual's care delivery. Attendees reported having improved their knowledge, confidence and skills in managing patients with frailty.
Strathcarron's work in the prison has also led to:
a monthly speech and language frailty clinic being set up in the prison
easier access to palliative care medication
motion sensors and night lights being purchased to help those who were falling overnight.
