The Community Frailty Hub brings together health and social care professionals from different organisations to support people living with frailty or long-term conditions.
Working closely with local GP teams, the team ensures patients receive the right care at the right time.
By integrating services and maintaining clear communication between teams, the Hub helps frail individuals stay independent for longer while improving their overall health and wellbeing.
The team aims to:
- Help reduce avoidable hospital admissions
- Support safe and timely discharge from hospital
- Enable people to stay independent for longer
- Provide responsive crisis care when needed
- Deliver person-centred care in the right place, at the right time
We make a difference through three key pillars of care
Prevention
The Prevention Team, within the Community Frailty Hub delivers person-centred care in the right place, at the right time, using a comprehensive geriatric assessment approach.
The team supports around 3,000 high-risk frail patients across York. This multidisciplinary team works closely with partners across the city to help individuals manage complex health needs and social challenges.
What patients can expect:
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An annual Comprehensive Geriatric Assessment (CGA) for a holistic review of health and wellbeing.
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A named Frailty Practitioner as a consistent point of contact.
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A dedicated phone line for advice and support during health or social difficulties, with direct links to the Frailty Crisis team if needed.
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Close collaboration with Primary Care to ensure seamless, coordinated care.
Crisis Support
The Frailty Crisis Service aims to provide holistic, wrap-round support for patients living with frailty in a time of crisis, whether this be medical or social.
The aim is to coordinate care, conduct medical assessments within 2 hours through the Urgent Community Response (UCR) service when required and support patients with the right help at home to prevent escalation of crises and avoid unnecessary hospital admissions whenever it is safe and possible to do so. This service runs seven days a week, 24 hours a day.
Who is involved during times of crisis
The team includes GPs with special interest in frailty, urgent community response (UCR) clinicians, Community Response Team, senior therapists, care navigators, social workers, social prescribers, Age UK support workers, and external partners of the wider Community Frailty Hub all working closely together.
How support is delivered
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The team discusses each case and agrees on the best support appropriate for the patient.
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Senior clinicians offer expert advice and guidance.
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The team coordinates care across different services to ensure a smooth and efficient response.
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The team keeps in touch and monitors patients throughout the crisis, until they can safely return to their usual care and support.
Supporting Hospital Discharge
The team helps people return home safely and smoothly after a hospital stay.
They work closely with hospital staff and community services to make sure each person gets the right support at the right time and help patients return home faster where possible.
Using an evidence-based discharge assessment, we help speed up discharges and provide extra support for those needing crisis care or therapy once they are back home.
How to access our Frailty Services
Any person on the Frailty Prevention caseload can call through to the CFH SPOC using the phone number they have been provided by their frailty practitioner.
Health and social care professionals can refer frail people into each of the different arms of the service by calling 01904 928844.