Access to community crisis and recovery services

(with active recuperation, rehabilitation and reablement) including frailty-focused transport and timely transfers of care from hospital involving families and carers.

What works

  • Offer crisis response with access to multi-disciplinary teams within 2 hours.
  • Single point of access with specialist opinion and diagnostics.
  • Design adequate and flexible step-up and step-down home-based and bed-based rehabilitation and re-ablement services.
  • Implement assertive discharge planning, early senior review, ‘discharge to assess’, a clear focus on flow and sharing information – ‘date of discharge’ within 2 hours and care package available within 24 hours of referral.
  • Adopt a trusted assessor approach with access to step-up and step-down home-based and bed-based services – 2 days target.
  • Adequate and timely information must be shared between services whenever there is a transfer of care between individuals or services.

  • Reduce the likelihood of living in residential care at six months’ follow-up when avoiding acute hospital admission
  • Decrease treatment costs compared with admission to acute hospital when excluding caregiver costs
  • Increase patient satisfaction
  • Reduce length of stay for people who can be safely discharged early from acute hospital
  • Increase the number of patients discharged home, rather than to an institution, after three months (although this was not sustained at six months)
  • Reduce ongoing care needs
  • Improve functional status when compared with usual home care

Evidence summaries

The National Intermediate Care audit summary report (2015) states that the ‘outcome evidence’ for intermediate care is multifaceted.  In terms of likelihood of returning home, improvement in activities of daily living, achievement of person specific goals, or structured assessment of care experience (PREMs) – all point to intermediate care doing its job of promoting and sustaining the desirable outcome of functional independence.  In addition, about two thirds of the service users replied that their social contacts had been definitely or to some extent improved helping them with their loneliness. National Intermediate Care (2015) summary report –

Hospital at home schemes that include multidisciplinary care and medical input can be effective and could support A&E based teams in reducing the need to access A&E. – Effectiveness Matters: Recognising and managing frailty in primary care – Centre for Reviews and Dissemination, The University of York —

Impact and Measures

We know that  frailty has a significant impact on people, populations and health and care systems. Frail older people are highly susceptible to adverse health outcomes, such as falls, disabilities, institutionalisation, hospitalisation and death. However, trying to understand this impact on populations and health and care system is challenging due to poor recording of frailty status and the lack of information sharing and interoperability that exists. The following examples of impact are guestimates based on current intelligence.


  • Potential Impact
    • The frail population (moderate and severe combined) makes up 2.44% of the population across the North East and North Cumbria, but account for 19.1% of general and acute bed usage.
    • In the North East and North Cumbria region the average length of stay in hospital was 7.9 days for a person with frailty compared to 4.4 days for a non-frail person and the 30-day emergency readmission rate for the frail population was 20.7% compared to 16.9% for the non-frail population.
  • Potential measures
    • People aged 65 years and over with severe frailty who have received an annual medication review
    • A&E attendance rates for patients aged 65 years and over
    • Emergency hospital admission rates for patients aged 65 and over
    • Proportion of stranded patients in hospital: Length of stay 7+ and 21+ days
    • Emergency readmissions within 30 days of discharge from hospital (patients aged 65 years and over)
    • Hospital activity in the last year of life (patients aged 65+ years)
    • Hospital Trust indicator set (Falls with harm, Pressure ulcers, Patient experience of hospital care, A&E waiting time 4 hour standard)


For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures in ‘word version of draft frailty toolkit’ page 79