Dr Matthew Butler is a Consultant Geriatrician at Cambridge University Hospitals NHS Foundation Trust. He writes on behalf of the EnRICH team, whose service evaluation is published in Age and Ageing.
Care home residents make up less than 1% of the population but account for around 8% of hospital admissions. Many of those admissions are distressing, some are avoidable, and a good number end in a hospital bed when the resident would rather have stayed in familiar surroundings. We wanted to know whether bringing integrated, geriatrician-led care directly to the care home, and keeping that same team alongside the resident if they did need hospital, could change that.
The problem we set out to address
Care home residents live with severe frailty and multimorbidity and frequently face complex decisions that are best supported by senior geriatric expertise, yet proactive specialist geriatric input often reaches them late, indirectly, or not at all. National policy, including the NHS England Enhanced Health in Care Homes (EHCH) framework and the NHS 10 Year Health Plan’s ambition to shift care from hospital to community, rightly promotes proactive multidisciplinary care; but the evidence base for models that actually embed a geriatrician in the care home setting remains thin. The handful of previous studies of geriatrician outreach reported only non-significant reductions in admissions. They also predate current service configurationsand tested one ingredient at a time rather than a joined-up, complex intervention.
Because those earlier models tested ingredients in isolation, we suspected that the missing piece was integration: combining proactive and reactive care within a single team and maintaining continuity when a resident crosses the community–hospital boundary.
What EnRICH actually does
EnRICH (Enhanced Reviews in Care Homes) is built around three components that work together rather than in isolation:
- Proactive care — scheduled comprehensive geriatric assessment (CGA), advance care planning and medication review for high-risk residents, delivered in the care home.
- Reactive support — telephone and email advice, in-home review during acute deterioration, and admission-avoidance pathways when a resident becomes unwell.
- Continuity across settings — the same geriatricians who know the resident are often able to review them when they do attend the emergency department or are admitted.
Crucially, the geriatrician works alongside GPs, community nurses, community pharmacists and care home staff within the existing multidisciplinary team. EnRICH is designed to complement EHCH provision, not replace it.
“EnRICH grew from a desire to provide greater support for care home residents and give them access to specialist care in the place they live, while also providing continuity when hospital care was needed. We also wanted to be more available to primary care colleagues and care home teams, helping them manage complex situations and sharing responsibility for some of the most challenging decisions. Ultimately, we wanted to deliver better, more coordinated care for residents and better support for the people caring for them.”
— Catriona Love, lead author and EnRICH service lead
What we found
We evaluated the service using a controlled before-and-after design, comparing 11 intervention homes with 43 contemporaneous control homes in the same catchment, and analysing 6,448 ED attendances with longitudinal fixed-effects regression and statistical process control charts.
Implementation of EnRICH was associated with:
- a 23% reduction in emergency admissions (rate ratio 0.77; 95% CI 0.60–0.97; p=0.03);
- a 32% shorter mean hospital length of stay (ratio of means 0.68; 95% CI 0.50–0.92; p=0.01);
- a point estimate suggesting 21% fewer ED attendances, although the confidence interval crossed the null (rate ratio 0.79; 95% CI 0.61–1.02; p=0.08).
Interestingly, the effect emerged gradually over the first 3 to 12 months, which we think reflects the time it takes to build relationships, embed advance care planning and weave CGA into care home routines.
The practical points for clinicians
If you are thinking about a similar model, our experience of leading the service — rather than the quantitative results presented above — suggests a few things matter more than others:
- Integrate proactive and reactive care in one team. Advance care planning alone changes where people die but does not reliably reduce admissions; pairing it with CGA, acute support and admission-avoidance pathways tackles the drivers of avoidable admission — acute deterioration, medication problems and the need for timely specialist review — that planning alone cannot.
- Continuity across the interface is critical. Being able to follow a known resident into the ED, and to support earlier discharge, is where much of the value sits.
- Give it time, and measure as you go. Benefits build over months, not weeks; statistical process control on routinely collected data let us monitor change in real time and reassure commissioners without waiting for a trial.
- Build on what is already there. EnRICH adds geriatrician expertise to an EHCH-style structure; it needs relationships and clinician time far more than new technology or infrastructure.
- Invest in the relationships. In our experience, much of the value came from care home staff and community colleagues feeling supported and listened to, enabling them to become more confident in caring for older people living with frailty.
What residents, families and staff told us
The numbers only tell part of the story. Care home staff valued being “given TIME to discuss a resident in depth and have someone LISTEN” and felt the service “definitely enhanced the care we provide”. A relative described not having to go to hospital to access a review and being met by “a sympathetic and understanding doctor who listened to my mother”. One primary care colleague called EnRICH “a much-needed service” that was “already making a meaningful difference”. This relational change, across care homes, primary care, community services and the hospital, was as striking to us as the admission figures.
Where next
This was a single-locality service evaluation with pragmatically selected homes, so selection bias and local context limit how far the findings generalise; replication in systems with differing EHCH maturity is needed before drawing wider conclusions.
“Good research in frail, complex, multimorbid elderly patients is notoriously hard to do, but this study demonstrates that it is possible! Routinely collected data, alongside rigorous statistical methodology, has been used to assess a new service which shows real benefits to frail care home residents, and I hope this will inspire similar projects across the nation.”
— Dr Joanna Hampton, Affiliated Associate Professor, Department of Medicine, University of Cambridge
Encouragingly, EnRICH is already moving from pilot to commissioned service, with the local ICS approving expanded funding for 2026–27. We hope our experience offers a practical, scalable template for others wanting to bring specialist geriatric expertise to care home residents living with frailty, where they actually live.
Read the Age and Ageing paper: EnRICH: an integrated geriatrician-led interface model associated with reduced emergency admissions among care home residents (Love, Butler, D’Souza et al.).
