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CCG develops an integrated hub within community setting to enhance efficiency and out-of-hospital care of frail patients, saving costs and boosting staff morale


    • 3100 patients were identified with severe frailty
    • Over reliance on inpatient care and recruitment issues drove the need for an anticipatory and out of hospital care approach for frail patients
    • Reduce emergency admissions and attendances by 10% with an average saving of £72/patient on drug costs 


    • Redesigned community frailty pathways led by local geriatricians, and CCG transformation lead to enhance care
    • Established a hub at the Integrated Care Centre (ICC) for efficient communication between hospital and community setting
    • Conducted Comprehensive Geriatric Assessments (CGAs) at patients home to obtain feedback and deliver person-centered care
    • Offered a dedicated transport service and meal to improve social engagement and inclusion


    • Reduced emergency admissions of patients reviewed at the ICC by 29% and at the targeted care homes by 24.3%
    • Saved an average of £110.17/patient on drug costs and improved patients quality of care while imparting a better understanding of their condition
    • Received positive staff feedback and 99% of patients are likely to recommend the service


Hull’s Jean Bishop Integrated Care Centre (ICC) welcomed its first patient in May 2018 - bringing in a new era of anticipatory, out-of-hospital care.

A fully re-designed community frailty pathway led by local geriatricians, and CCG transformation lead with many years’ Emergency Department experience, sees GPs, advanced nurse practitioners, social workers, pharmacists and other specialists working for the first time as a single system. The new bespoke ICC building provides the hub for integrated working, and the clinical leadership model is engaging and facilitating clinical teams working across traditional boundaries of hospital and community settings, with a real focus on quality.

This has been a five-year vision and, in recognition of the complexity of the challenge, is intentionally phased to get real results for patients. Strong working relationships between health and Local Authority have eased integration- something not experienced in every area nationally.

Listening to patients has been key to success - Comprehensive Geriatric Assessments (CGAs) involve a home visit from clinical staff where patient and carer explain their needs and issues, which are not all health-related. This information forms the basis of the person-centred assessment at the ICC.

We’re a proud ‘Ageing Well’ case study in the NHS Long Term Plan


Hull’s predicted demographics, the system’s over-reliance on hospital care, plus workforce issues drove the need for a new structured, anticipatory approach, led by community geriatricians, to modernise the service model for frail patients with complex needs; moving from an individual provider focus to a systemwide perspective.

Benefits realisation targets included:

  • 10% reduction in Emergency Department attends
  • 10% reduction in emergency admissions
  • An average saving of £72 per patient on drug costs (based on 2016 evaluation from care homes
  • Reduction of patients going into ED from care homes and GP call outs

Following a public consultation, Phase One introduced anticipatory, integrated assessment and care planning for the 3100 patients (including care home residents) identified as being at risk of severe frailty using the elderly Frailty Index (eFI) tool.

This proactive approach would involve up to 21,000 interventions via dedicated inter-disciplinary team in the newly established ICC building- including medical teams, nurses, pharmacists, therapists, social care, carers support and voluntary sector. Key upstream pathways were also redesigned as part of the process.

A collaborative, multi-disciplinary Project Board and Steering Group were established to provide strategic planning and involvement of partners, clinicians and build on the patient engagement.


Funding has not been taken away from the hospital to enable this service model to be delivered in the community. The Aligned Incentive Contract with the local acute trust includes minimal levels of growth, enabling the CCG to utilise its financial allocation to fund the service. A contractual minimum dataset informs evaluation and outcomes (document available).

At six months, patients and carer’s survey feedback highlights the importance of care quality, quality of life and the value of the service to them. They have related to feeling better following medication changes, or being able to move more safely to get out and about. Patients have expressed relief at having better understanding of their condition, what to expect and a prognosis. Since May 2018 real results are being seen in the targeted cohort:

• 1646 patients and care home residents have received a CGA

• 29% reduction in emergency admissions for patients reviewed at the ICC (living in their own homes)

• 24.3% reduction in emergency admissions in patients reviewed in the targeted care homes

• average £110.17 saved per patient, per year, on drug costs

• 99% of patients extremely likely/likely to recommend the service


On the strength of this project we:

  • Successfully recruited and trained 9 GPs as GPs with an Extended Role in Older People (GPwER)
  • Received funding for new innovate GP Vocational Training Posts in Community Geriatrics and recruited to these posts at a time of national shortage
  • Provided support and mentorship to other professional groups outside integrated care and rotational posts across providers
  • Active interest from Senior Hospital Registrars
  • Hospital consultant teams from chronic disease specialties stepping forward to be actively involved during phase two

We’ve received significant national interest in our collaboration and visits from NHSI/NHSE and neighbouring trusts to see how the model can be replicated in other community settings. Plans are in place for the establishment of the ICC as a Parkinson’s, COPD and Dementia Hub. Frailty leads for GP groupings and community nursing teams have opportunity for regular and formal dialogue with ICC lead clinicians and influence prioritisation of the practices, ongoing modification and development of clinical model.

We are actively involved in research in a cohort of patients rarely involved in research– i.e. frailer patients. We’ve identified where we can integrate frailty services with chronic disease specialties to reduce duplication, fragmentation and waste.


A core staff group was created from an existing, redesigned workforce. Staff recruitment and retention was identified as a key risk, and change has been managed through communication and engagement between organisations, resulting in minimal de-stabilisation across the system.

To mitigate DNA rates, which are low, we offer a dedicated transport service and meal in the voluntary service café to improve social engagement and inclusion. A conservative estimate has been included for the medication savings expected for phase one of the scheme. It is anticipated this will increase as the community frailty pathway becomes more established and the cohort of patients benefitting from the development expands to include Hull’s 9000 moderately frail patients. Surveys with patients, carers and staff have given a vivid insight into the impact the ICC is having on the lives of older, frail people in Hull, with patients reporting they:

  • felt supported by the range of healthcare professionals
  • had adequate time and opportunity to discuss any worries or fears
  • healthcare professionals had enough information about their medical history
  • had enough time to discuss their health or medical problems
  • felt informed and empowered during their consultation and in planning their future care plan.



  • Listened to the views of 700 people in our public consultation and were commended by Council for our approach
  • Tested model with fewer patients for feedback
  • Tested branding of ICC
  • Engaged with local voluntary groups to produce artwork- enhancing therapeutic environment.

We are committed to working with patients on phase two, which includes involving Parkinson’s UK and others.

Humberside Fire and Rescue has an operational fire station on site and provides a falls response team and supports rehabilitation of patients. The service works in an integrated way with local GPs, who follow up on the CGA and come back to the ICC team if advice is needed. There’s no takeover of their patients- the CGA is a structure for them to work from. Each of five groupings has a frailty lead and regular dialogue helps influence decision-making around how we prioritise- tackling severely frail patients first.

The involvement of carers and inclusion of carer support in the CGA is one of the elements that makes the approach at the ICC unique (i5) plus a leadership model that uses the geriatricians as credible negotiators to bring about the transformational and sustainable change needed across our system.