York Community Frailty Hub
System Update
The York Community Frailty Hub was established in November 2023 to address the fragmented support for older people in the community. The Hub is an integrated multidisciplinary initiative designed to proactively manage frailty within the community. This service provides frailty prevention, crisis response, and discharge support, aiming to reduce hospital admissions and improve the quality of life and health and social care outcomes for frail individuals in York.
The York Community Frailty hub team is comprised of co-located frailty nurses, physiotherapists, occupational therapists, dieticians, social prescribers, social worker, health support workers, GPs with a special interest in frailty, GPs with a special interest in dementia, memory support advisors, dementia nurse, palliative care nurse, Age UK support workers, North Yorkshire Sport personal therapists, Carer’s Centre support workers, care navigators and care co-ordinators.
The York Community Frailty Hub is delivering impactful, coordinated, and cost-effective care for some of York’s most vulnerable citizens and is being recognised nationally as an example of excellent integrated delivery of Community Care. Continued investment in this model promises further efficiencies, reduced hospital admissions, better outcomes, and an enhanced community care experience. This integrated service is evolving at pace and finding efficiencies whenever possible.
