This project aims to improve care for people with frailty, including those with learning disabilities, by providing six weeks of remote monitoring and proactive support after hospital discharge. The goal is to reduce hospital readmissions and help these patients live independently for longer, potentially improving how the NHS cares for individuals with frailty in the community.
Background
Frailty is a major challenge for the NHS, affecting many older people. People with frailty are more likely to need longer or more frequent hospital stays, experiencing serious health issues and a decline in independence. Functional impairment, cognitive decline and limited social support hinder patients’ ability to manage their own health. Despite known risks, hospital discharge planning often fails to account adequately for the complexity of frailty, contributing to unmet care needs and avoidable readmissions. These challenges are compounded for patients with frailty who also have Learning Disabilities (LD), who facing a higher risk of deterioration and poorer long-term health outcomes. These patient groups are often discharged from hospital onto social care pathways with only general practice clinical input.
By offering patients with frailty on three existing social care post-discharge pathways access to six weeks of remote monitoring technology (RMT) and proactive care, we seek to ascertain whether this intervention can reduce the likelihood of readmission to hospital and support independent living for longer. If successful, this approach could lead to wider adoption, transforming the way we care for people with frailty in the community.
This project, part of Hertfordshire NHS Community Trust Health (HCT) proactive and anticipatory care initiative, is a partnership between HCT, Health Innovation East and ARC East of England, alongside tech partner Doccla.
Project Aims
- Generating evidence regarding RMT interventions to reduce rates of hospital readmission for people experiencing frailty, including those with learning disabilities.
- Increasing research capacity and capability within the community sector.
Anticipated or actual outputs
- Address a gap in evidence regarding the utilisation of RMT in people with frailty on social care pathways
- Address a gap in evidence regarding intersection of frailty and learning disability healthcare outcomes
Who is involved?
- Dr Elizabeth Kendrick, Chief Medical Officer, Hertfordshire Community NHS Trust (HCT) (PI)
- Dr Paul Williams, Academic Research Fellow, HCT
- Prof Andrew Clegg, Professor of Geriatric Medicine and Head of Ageing and Stroke Research, University of Leeds
- Amanda Busby, Research Fellow and Medical Statistician, University of Hertfordshire
- Dr Carole Gardener, Senior Research Associate, University of East Anglia
- Cathy McCabe, Associate, Health Innovation East
Contact
Cathy McCabe- cathy.mccabe@healthinnovationeast.co.uk
