Warwickshire frailty service keeps half of patients at home after falls

Case study summary

An innovative, partnership approach to caring for the frail and elderly in Warwickshire has led to a frailty service that is keeping 50% patients at home after a fall, with just 3% having to return to hospital at a later date, down from 15%.

When paramedics visit someone whose had a fall, they can call a frailty phone for advice from frailty consultants and Advanced Care Practitioners (ACP). Every discharged patient over 75 is called by a nurse and to support the service, a partnership with Warwickshire Fire and Rescue means they are assessing the risk of slips, trips and falls and bringing food bags to patients’ homes, to prevent them going back to hospital.


  • Coventry and Warwickshire Integrated Care System (ICS)
  • South Warwickshire NHS Foundation Trust

The aim

With a high and growing elderly population, Coventry and Warwickshire ICS recognised there was a need to prevent frail elderly people being admitted to hospital, to reduce their length of stay if admitted and prevent re-admission, both because this is best for patients but also reduces pressure on the whole system.

The vision is to provide care as close to home as possible so that all patients over the age of 75, or patients that are frail and in a care home under the age of 75, are assessed and seen by a frailty consultant early in their journey. If frail patients don’t see a frailty consultant their length of stay in hospital goes up as they haven’t received comprehensive geriatric assessment.

The solution

  • Providing a frailty phone that paramedics can call on scene for advice and triage from a frailty consultant, supported by an ACP. Together they decide whether a patient needs to go to hospital or can stay at home.
  • Setting up a discharge pilot where a nurse phones every frail patient over 75 the day after they are discharged.
  • Working in partnership with Warwickshire Fire and Rescue so that if a patient is taken home by the service, they carry out safe and well checks, asses slips trips and falls, fit smoke alarms, provide smoke retardant bedding, look for signs of fraud, provide food packages, and check electric blankets and tumble dryers.
  • Work closely with Adult Social Care so that if patients already have packages of care they are restarted as much as possible.
  • Hold community multi-disciplinary team meetings twice a day where every patient is discussed. This develops really strong links with local care homes and discharge liaison teams on frailty wards, so patients are supported to go home when it’s safe to.


Rachel Williams, Associate Director of Operations, Emergency Division, South Warwickshire NHS Foundation Trust said, ‘It’s always challenging to decide whether a patient should be admitted to hospital or not, so you need to persevere with any new service and know it’s the right thing to do for the patient to make these decisions in a different way. You also need to bang the drum. When calls drop off, we phone the help desk at the ambulance service and say, don’t forget we’ve got a frailty phone.

‘We remind paramedics to send us frail elderly patients we could divert, as we need them to use the service for it to work. Engagement with partners to make it a success is always challenging, winning over hearts and minds, but we are very lucky as we have a geriatrician workforce that wants to join us as the team has a fantastic reputation.’


As a result of the service, 50% of patients who have a fall are cared for at home. In the discharge pilot, when a frail patient over 75 is sent home, they are phoned by a nurse the next day, which has led to hospital re-attendances going from 15% to 3%.

If patients go home sooner, they need less social care support and they are less likely to become lonely. A multi-disciplinary approach with safe and well checks focusses on prevention and aims to prevents patients from losing condition – when inactivity leads to loss of fitness or muscle tone.

Learning points

  • Having a trained community ACP workforce that can review patients makes a huge difference. Former trainees are now qualified, so having a vision and sticking to it is important as training up staff is vital to take a new service forward.
  • The frailty phone has no criteria as its preferable that people phone and get advice than have strict criteria and nobody calling.
  • Recognising that your vision may also meet the vision of your partners is important. What we want to achieve also fits with Warwickshire Fire and Rescue’s overall strategy, which is care closer to the community to prevent fires. Working with the frailty service is giving them the population that they need to reach, so it’s a great example of strong partnership working.

Next steps?

  • To broaden the existing virtual ward which currently cares for patients who are visited by community ACPs
  • To widen the scheme that delivers antibiotics into care homes for patients with urinary tract infections and cellulitis – to prevent admission into hospital
  • To have regular patient meetings with surgical teams about how their patients will be discharged.

Find out more?

Contact: england.stcomms@nhs.net