Right time, right place: Urgent community-based care for older people
This document outlines the offers and services currently delivered across the country in pursuit of a broadly similar aim to provide appropriate, timely, high-quality care when an older person experiences a crisis or urgent need. It details some examples of how urgent care can be provided outside the hospital environment. We also provide tips for BGS members who want to start providing this type of care to their older patients, and call on commissioners and governments to make the provision of care at or near to home easier for healthcare professionals and patients.
The British Geriatrics Society (BGS) is committed to improving healthcare for older people, in the most appropriate setting for the individual. In recent years there has been an increasing focus on the healthcare that is provided outside the acute hospital environment, either in the patient’s home or in a community setting. Various models have emerged, particularly for the provision of urgent care out of hospital.
2. Our vision for urgent care
Older people wish to lead healthy, independent and active lives for as long as possible. With the process of ageing, more people develop long term conditions, frailty and other impairments such as dementia.
3. Principles for urgent care
- Care should be delivered at or as close to home as possible, enabling older people living with frailty or other conditions to stay in or return to the comfort and familiarity of their usual place of residence as quickly as possible, balancing the risks and benefits of hospital admission with the risks and benefits of care at home.
- Any additional support required for acute care based in the home must be provided.
- Urgent care response services should complement and connect to other services seamlessly, so that older people experience joined-up care rather than fragmented services. Healthcare, social care and the voluntary sector should be integrated to provide person-centred care.
- Appropriate urgent responses should be delivered in a prompt timely manner.
- Multidisciplinary teams (MDTs) provide the range of skills and competencies to deliver urgent care and should include doctors or advanced practitioners who have the ability to assess, diagnose and treat in an urgent care setting.
- First responders such as ambulance services and NHS 111, local community services, carers and older people themselves should be made aware of what urgent care services are available in an area with simple single point of access referral processes, including self-referral, put in place.
- Urgent care services should be available to all older people, including those living in care homes.
- Patient records such as Comprehensive Geriatric Assessments, Advance Care Plans and Treatment Escalation Plans should be made available so that urgent care teams have access to the information they need to diagnose and treat, and all parties involved in older people’s care have access to accurate, up-to-date patient information.
4. The case for a range of options
Well-designed systems for assessment, diagnosis and treatment through services provided at or closer to home supported by point of care or near patient testing or using hospital-based same day emergency care (SDEC) can provide a credible alternative to hospital admission for managing acute illness and ensure that ongoing care is put in place swiftly.
5. Options for alternatives to hospital
This section aims to briefly outline the main models currently in existence providing urgent care in England outside an acute care setting.
This list may not be exhaustive as additional models may exist for specific patient groups or in specific localities. Each description sets out the features of the model and the benefits and limitations. While these descriptions specifically discuss individual models, it is important to note that there are increasing overlaps and hybrid models being developed with elements of H@H and UCR. These are often pragmatic responses to the demands of different localities and availability of resources, and have similar aims to provide alternative options to hospital admission.
a. Hospital at Home (H@H)
More details can be found here.
b. Urgent community response (UCR)
More details can be found here.
c. Same Day Emergency Care (SDEC)
More details can be found here.
d. Frailty Assessment Units (FAUs)
Details of an example of a Frailty Assessment Unit can be found here.
e. Virtual wards
6. Supporting structures
The models outlined all share a common aim – to offer older people with frailty a viable high-quality alternative to hospital admission, minimising the time they spend in hospital and/or delivering processes of care in community settings that have previously only been available in hospital.
a. MDT-led Anticipatory Care
b. Enhanced health in care homes (EHCH)
c. RESTORE2 and other early warning systems
7. Tips to get started
- Plan the right service for your area. None of the services outlined are intrinsically more suitable than the others – consider what will work best for your population, the geography of the area you serve, the services you already have in place and the capacity available. You may well develop a hybrid model most suited to your locality. Assessments such as those offered by Getting It Right First Time (GIRFT) visits may be helpful in providing an understanding of what might need to be developed.
- Be realistic about funding and resource. Work with the resources you have, to maximise the use of current services and personnel. Additional funding may not be available so you may need to repurpose the working of existing multi-disciplinary teams. Aim to provide a good service for many, not an excellent service for only a few. This may mean building gradually towards some of the more resource-intensive options.
- Engage with all colleagues providing frailty-based care, including your acute hospital colleagues. These services work best when community services work in partnership with colleagues in acute hospitals.
- Don’t forget the communications. Whatever you do, make sure that when developing a new service, you involve others who need to know about it, from first responders such as ambulance services and NHS111 through to voluntary sector agencies.
- It doesn’t end with you. Whatever service is implemented, it is unlikely that the individual’s needs will have been met entirely. It is crucial that the service links with other services that can provide ongoing support and monitoring as needed.
8. What is needed to make this a reality?
While implementing services to provide urgent care at home requires dedicated local capacity, support is needed from central bodies and ICSs to make this a reality across the country. In order to make this happen, we call for:
- Commitment to implementing the principles set out above to deliver a high-quality person-centred experience of urgent care for older people.
- Coordination and linkage of services to enable delivery of coherent and efficient services for people living with frailty.
- Sharing of good practice, so that all regions and local areas are supported to learn from each other, coalesce around a common language and avoid duplication and fragmentation of services.
- Communication between providers so that proactive and reactive services are joined up, and patient records are shared with appropriate information governance in place.
- Appropriate resources to be identified to ensure all people living with frailty have clear, effective and sustainable alternatives to hospital admission where appropriate.
- Investment in technology to ensure excellent communication between primary, secondary and community care.
The BGS believes this vision is within reach if there is the will to make it happen.
90% of the deaths from COVID over the last year were in people aged over 65. As services gradually resume post-COVID and the long-term effects of the pandemic become apparent, now is the critical time to ‘build back better’ and seize the opportunity afforded by the NHS Long Term Plan, with its focus on delivering more care for older people closer to home. Ensuring that the urgent care initiatives described above are coordinated will reduce duplication and enable older people living with frailty to receive assessment, diagnosis and treatment appropriate to their urgent care needs.
- Shepperd S, Butler C, Cradduck-Bamford A, Ellis G, Gray A, Hemsley A, Khanna P, Langhorne P, Mort S, Ramsay S, Schiff R, Stott D, Wilkinson A, Yu L, Young J, 2021 Is Comprehensive Geriatric Assessment Admission Avoidance Hospital at Home an Alternative to Hospital Admission for Older Persons? Annals of Internal Medicine, https://doi.org/10.7326/M20-5688.
- NHS England, 2021. Community health services two-hour crisis response standard guidance. Available at: www.england.nhs.uk/publication/community-health-services-two-hour-crisis....
- NHS England. 2021/22 priorities and operational planning guidance. Available at: www.england.nhs.uk/publication/2021-22-priorities-and-operational-planni...
- NHS England. The Framework for Enhanced Health in Care Homes: Version 2. 2020. Available at: www.england.nhs.uk/community-health-services/ehch.
- Dr Shelagh O’Riordan, Consultant Community Geriatrician, Kent Community Trust; Chair, BGS Community Geriatrics SIG
- Dr Michael Azad, Consultant Physician, Nottingham Universities NHS Foundation Trust; Chair, BGS England Council
- Dr Jennifer Burns, Consultant Physician, Glasgow Royal Infirmary; BGS President
- Dr Esther Clift, Consultant Practitioner in Frailty, Southern Health NHS Foundation Trust; Chair, BGS Wessex
- Prof Adam Gordon, Professor of Care of Older People, University of Nottingham; BGS President Elect
- Dr Eva Kalmus, Interface Medicine GP, Sutton Health and Care At Home; Co-chair, BGS GeriGP Group
- Dr Maggie Keeble, Care home GP and Clinical Lead for Integrated Care Systems, Worcestershire Health and Care Trust; Co-chair, BGS GeriGP Group
- Prof Daniel Lasserson, Professor of Acute Ambulatory Care, University of Warwick
- Prof Finbarr Martin, Emeritus Geriatrician and Professor of Medical Gerontology, King’s College London
- Sarah Mistry, BGS Chief Executive
- Sally Greenbrook, BGS Policy Manager