Abstract
Introduction
Frailty in older adults increases risk of hospital admission, prolonged stay, and poorer outcomes. The NHS Long-Term Plan emphasises early identification, admission avoidance, and shifting care into the community to reduce system pressures and improve patient outcomes. Bromley has one of the largest and fastest-growing older populations in South East London. The One Bromley Hospital at Home (H@H) service is a multidisciplinary, person-centred service, integrating step-up and step-down pathways. Dedicated frailty and palliative care arms ensure high-risk patients receive coordinated, specialist-led care, embedding multidisciplinary meetings with geriatricians and palliative care teams.
Methods
A one-year retrospective evaluation (April 2023–2024) assessed service utilisation, clinical outcomes, technology integration and patient satisfaction for frailty/palliative arms of this service.
Results
• Service growth: H@H referrals tripled from 32 to 107 (April 2023 vs 2024). Over the year, 800 patients received care with 17,400 patient contacts, 53% face-to-face. • Frailty and palliative care expansion: frailty referrals increased by 200% contributing 45% of H@H referrals, palliative referrals accounted for 15%, supporting complex end-of-life care at home. • Patient Profile: average age 84.1 years; 55.1% male • Pathway Impact: step-down referrals (62%) facilitated early hospital discharge, whilst step-up admissions (38%), prevented acute hospitalisation. Frailty vs Palliative LoS were 8 vs 4.5 days respectively. • Digital Integration: 25-30% of patients benefited from remote monitoring, reducing hospital escalation and improving clinical oversight. • Readmission rates averaged 12.5%, reflecting the complexity of the caseload. • Patient satisfaction remained consistently >90%, highlighting positive patient experience and acceptability of home-based frailty care.
Conclusion
This H@H model aligns with national UEC transformation priorities by: reducing hospital dependency through proactive frailty management, integrating frailty/palliative pathways within the virtual ward, enhancing health equity and access to out-of-hospital care. Future research to evaluate long-term sustainability and cost-effectiveness is key before wider adoption across Integrated Care Systems.