Using a neighbourhood model to better support frailty patients

Key benefits and outcomes

• 28–49 per cent reduction in A&E attendances among frail patients using the service.
• £209,653 total savings over 12 months through deprescribing and avoided adverse events.
• 3,586 care home residents reviewed through proactive weekly ward rounds.

What the organisation faced

Apollo PCN’s neighbourhood of Warwickshire North has high levels of deprivation, complex long term conditions and significant frailty. Rising emergency demand and fragmented care meant that deterioration was often identified too late, leading to avoidable A&E attendances, unplanned admissions and pressure on general practice and community teams.

Care homes reported inconsistent clinical oversight and system partners highlighted gaps in anticipatory care, medicines optimisation and continuity. Apollo PCN recognised that a neighbourhood based, multidisciplinary model was needed to intervene earlier, support patients before crisis and strengthen coordination across primary, community and acute services.

What the organisation did

Apollo PCN designed a neighbourhood frailty model built around two core components: a frailty hub MDT clinic and a weekly care home ward round programme. Together, these form a proactive, integrated approach that brings care closer to home and ensures frail patients receive the right support at the right time.

The frailty hub

The frailty hub offers 1.5-hour multidisciplinary appointments for identified cohorts of frail patients. Each clinic brings together healthcare assistants, clinical pharmacists, physiotherapists, occupational therapists, advanced clinical practitioners (ACPs)/GPs, social prescribers and Citizens Advice. 

Patients receive a comprehensive review covering lifestyle, observations, ECG, blood tests, falls risk, mobility, daily living, medicines optimisation and advance care planning.

Pharmacists lead structured medication reviews focused on polypharmacy, deprescribing and shared decision making. Therapy teams assess mobility, home safety and falls risk, often arranging home visits to prevent deterioration. 

ACPs and GPs provide holistic physical, mental and social assessments, and make onward referrals. The model is delivered through a hub and spoke approach across practices, ensuring consistency and accessibility.

Weekly care home ward rounds

Alongside the frailty hub, Apollo PCN introduced a planned weekly ward round model across eight care homes (417 beds). Led by an enhanced nurse/ACP with GP support, the model provides structured clinical oversight for frail and complex residents. The ward rounds established base lines for frailty within each care home, covering medication optimisation, falls risk, advance care planning and alignment with QOF requirements.

The ward rounds operate as a neighbourhood MDT hub, linking general practice, pharmacy, AHPs, and specialist pathways. This coordinated approach ensures earlier identification of deterioration, more consistent personalised care planning and smoother escalation when needed.

The PCN strengthened collaboration across the neighbourhood by co locating services and aligning operational models. Enhanced access was redesigned with community pharmacy, acute trust teams supported pulmonary rehab and frailty front door pathways, and the mental health trust located its community dementia service within the frailty hub.

The PCN also partnered with Coventry and Warwickshire Training Hub to create a learning environment for student clinicians and GP Vocational Training Scheme trainees.

To understand the impact of the new model the PCN worked with Health Data Intelligence to evaluate pre  and post intervention outcomes across primary, community and secondary care. This provided a robust evidence base for system impact and future development.

Results and benefits

The neighbourhood frailty model has delivered significant improvements for patients, practices and the wider system.

Frailty hub outcomes

Since April 2025, the frailty hub has seen 1,140 patients and completed 8,640 medicines reviews. Deprescribing and medicines optimisation prevented 39 adverse events, saving £117,057, alongside £59,943 in drug savings. Total savings over 12 months reached £209,653. Patients reported improved understanding of their medicines, fewer side effects, better compliance and greater confidence in managing their health.

Care home ward round outcomes

Across the eight care homes, 3,586 residents have been reviewed through 273 face to face visits, with 235 onward referrals to MDT services. Emergency admissions fell by 44 per cent among severely frail residents, and A&E attendances reduced by 21 per cent. Earlier intervention and stronger anticipatory care have improved continuity and reduced reliance on urgent pathways.

System impact

The model has shifted care away from high cost emergency services towards proactive primary care. Increased GP activity reflects earlier intervention and more structured follow up, while reductions in community hospital use and emergency admissions demonstrate meaningful system savings. MDT coordination has improved efficiency, reduced duplication and strengthened relationships across sectors.

Patient experience

Survey findings show strong support for neighbourhood aligned care. Patients value continuity, proactive long term condition management and seeing familiar professionals. Many reported improved wellbeing, confidence and activation, and expressed concern about losing neighbourhood based care if services were organised over wider footprints.

Overcoming obstacles

Implementing a neighbourhood frailty model required sustained engagement with care homes, consistent clinical presence and relationship building. High deprivation and complex needs meant the MDT approach had to be flexible and personalised. Data gaps in community activity required closer collaboration with system partners, and workforce pressures were addressed through structured team development, communication training and MDT support.

Takeaway tips

• Build a consistent clinical presence in care homes to strengthen trust and continuity.
• Create a baseline for the whole care home, identify unmet need early and target MDT input.
• Invest in structured MDT clinics to reduce fragmentation and improve proactive care.Align neighbourhood services physically and operationally to improve access and integration.
• Use data driven evaluation to demonstrate impact and secure system support.
• Prioritise medicines optimisation — deprescribing delivers significant patient and system benefits.

Further information

For more detail on this work, contact Dr Mehwish Qureshi: mehwish.qureshi@nhs.net