When the York Community Frailty Hub opened its doors in November 2023, it marked a turning point in how frail and vulnerable people are supported in the community.

Designed to tackle fragmented services, the hub brings together General Practice, the Acute Trust, Local Authority, Adult Social Care, Community Services, Ambulance Service, and voluntary sector partners into one integrated system.

“Before the hub, services were working in silos,” explains Dr Emma Olandj, Clinical Lead of the York Community Frailty Hub, “We already had a frailty prevention team, the York Integrated Community Team, but during COVID it became clear that frail patients needed more than isolated interventions.

We trialled models where I manned a phone line to help avoid admissions, and that showed us the potential for something bigger. What started out as a few calls has grown into a fully integrated service that’s changing lives.”

That “something bigger” evolved into a three-part service:

• Frailty Prevention Team – providing proactive case management and annual Comprehensive Geriatric Assessments (CGAs) for over 3,000 of York’s most complex patients.
• Frailty Crisis Response Team – offering rapid multidisciplinary support and a dedicated 24/7 Advice & Guidance (A&G) line as an alternative to 999.
• Discharge Support Team – helping medically fit patients leave hospital sooner with bridging care packages and therapy input.

We wanted to stop bouncing patients around between our services,” says Dr Olandj. “Now, whether it’s prevention, crisis, or discharge, we respond quickly and collaboratively. Every patient has a named frailty practitioner and direct access to the hub’s single point of contact.”

“In the first six months, we prevented over 2,000 admissions and saved more than 1,000 bed days. But the real success is the difference in people’s lives – keeping them safe, independent, and supported at home.” Professor Mike Holmes, GP Partner at Haxby Group and chair of Nimbuscare.

Reducing hospital admissions and improving patient outcomes

The hub’s impact has been dramatic. Over the past year, the Frailty Crisis team has prevented 4,501 patients from attending A&E or requiring a 999 call.

In 84% of cases, paramedics avoided hospital transfers thanks to timely advice from the advice and guidance line. Most importantly 89% of those patients remained safely at home two weeks later, proving the effectiveness of the model.

“That’s the powerful statistic,” says Professor Mike Holmes, GP Partner at Haxby Group practices and chair of Nimbuscare, the primary care provider that runs the hub. “It’s not just about avoiding admission on the day – it’s about keeping people well at home. Historically, patients with delirium or falls would have gone straight to hospital. Now, with the right support, we can manage them safely in the community.”

The discharge arm has delivered equally impressive results. By actively pulling patients out of hospital and providing short-term care, the hub has saved over 1,000 bed days in six months and cut the average length of stay from nine days to one for frail patients deemed fit for discharge.

“That reduction isn’t just a cost saving,” Professor Holmes stresses. “It prevents deconditioning, reduces morbidity, and helps people recover faster. It’s a human saving.”

Helping elderly patients avoid crisis point

When an 86-year-old gentleman fell at home, his daughter called the frailty crisis line. A rapid two-hour response was arranged, and medication was reviewed. Despite another fall the next day, the hub coordinated therapy and short-term step-up intermediate care. Eight days later, he returned home safely with ongoing support.

“Historically, he may have been admitted for a number of weeks,” says Dr Olandj. “Instead, we kept him safe and independent.”

Supporting timely discharge and preventing decline through the multidisciplinary team

The discharge arm has delivered equally impressive results. By actively pulling patients out of hospital and providing short-term care, the hub has saved over 1,000 bed days in six months and cut the average length of stay from nine days to one for frail patients deemed fit for discharge.

One 80-year-old woman, admitted with acute confusion, faced a nine-day wait for social care assessment. The hub intervened, arranged a bridging care package, and had her home within 24 hours. Within two weeks, her care needs reduced dramatically, and she regained independence. “That reduction isn’t just a cost saving,” Professor Holmes stresses. “It prevents deconditioning and helps people recover faster.”

Another patient, living with her husband, was referred after a fall and subsequent overdose. The prevention team carried out a comprehensive geriatric assessment (CGA), identified mental health and mobility issues, and coordinated support from occupational therapy, dietetics, and social prescribing. Today, she remains at home with a personalised care plan and improved wellbeing.

The service began as a small pilot, operating a few days a week. Today, it runs 24 hours over 7 days. The team is also introducing dementia diagnostic capability, integrating end-of-life care, and exploring AI technology to support high-intensity users at home.

“We’ve been able to innovate because we’re rooted in the community,” says Professor Holmes.  “As a GP-led provider, we can hold clinical and financial risk, invest in services, and move quickly.”

At the heart of the hub is a co-located multidisciplinary team (MDT). Frailty nurses, GPs with a special interest in frailty, occupational therapists, dietitians, dementia nurses, social prescribers, Age UK support workers, and social workers all work side by side. This proximity speeds up decision-making and eliminates delays caused by traditional referral processes.

Says Dr Olandj; “The conversations we have across the office save hours – and sometimes save lives.”

The hub also supports Yorkshire Ambulance Service through the ‘Call Before Convey’ initiative, enabling paramedics to consult the frailty team before deciding on hospital transfer. This partnership has driven a surge in advice and guidance line activity, reflecting growing confidence in community-based care.

Making a difference for patients and their families with personalised care

Looking ahead, longer term aims for the hub is to become a Frailty Training Centre, participating in national research, and strengthening links with Emergency Departments to bring frail patients home from the front door. This move towards a community model fits in with the aims of the 10-year health plan and the hospital to community and sickness to prevention shifts.

“This is about creating a seamless, person-centred system,” Dr Olandj explains, “Frailty will remain at the core, but the hub is becoming the glue that holds wider community services together.”

For patients and families, the benefits are tangible: fewer hospital stays, faster recovery, and care delivered in familiar surroundings. For the system, it means reduced pressure on acute services and better use of resources. As Professor Holmes sums up:
“In the first six months, we prevented over 2,000 admissions and saved more than 1,000 bed days. But the real success is the difference in people’s lives – keeping them safe, independent, and supported at home.”

Watch Dr Emma Olandj introduce the York Community Frailty Hub in our video