Some patients who might traditionally require a hospital bed can instead receive daily consultant-led care in the comfort of their own home, thanks to our Community teams in Calderdale. 

The Frailty Hospital at Home service, which became a standalone service in May 2025, is helping older people across Calderdale receive hospital-level care at home, avoiding unnecessary admissions and supporting earlier discharge from hospital. The service supports older people who are living in Calderdale and registered with a Calderdale GP Practice. 

Frailty Hospital at Home provides short-term, intensive clinical support for people aged 65 and over who are living with frailty and whose condition would otherwise require an acute hospital bed.

The service offers both:

Step-up care: helping people remain at home when they become unwell and would otherwise be admitted to hospital.

Step-down care: supporting a safe and timely discharge from hospital while continuing treatment, monitoring and consultant oversight at home.

The team has capacity for 22 patients and delivers care seven days a week, with daily visits available between 8am and 6pm.

Patients are reviewed by a consultant-led multidisciplinary team every weekday, ensuring treatment plans can be adjusted promptly as patients recover.

The Frailty Hospital at Home team brings together specialist practitioners from a range of professional backgrounds, including:

• Nursing
• Physiotherapy
• Occupational Therapy
• Paramedic practice

Working closely with patients, carers, GPs, community teams and hospital colleagues, the service provides daily clinical assessment, treatment, monitoring and review.

The team supports patients experiencing:

• Subacute infections
• Exacerbations of long-term conditions
• Moderate to severe frailty-related symptoms
• Early signs of deterioration or delirium
• Ongoing recovery following an acute hospital admission

For many patients, remaining in familiar surroundings can reduce anxiety, support recovery and enable them to stay close to the people, routines and possessions that matter most.

One recent patient story highlights the difference the service can make. A woman living with advanced dementia was referred to the Frailty Hospital at Home team with hypoactive delirium, acute kidney injury and an infection. Previously active and regularly attending a day centre, she had become bed-bound, unresponsive and was eating and drinking very little.

In line with her wishes and RESPECT care plan, her husband was keen to avoid hospital admission. The Frailty Hospital at Home team provided intravenous fluids, daily monitoring and ongoing clinical assessment, while also supporting her husband with advice and guidance.

Within days, her condition improved significantly. Her infection markers normalised, her kidney function stabilised, and she became more alert, resuming eating and drinking as she recovered at home.

Could your patient benefit?

Step-up referrals

Patients may be suitable if they:

• Are aged 65 or over with a Rockwood Frailty Score of 4-9
• Require short-term treatment for up to 14 days that would otherwise need an acute hospital bed
• Have a subacute infection and are clinically unstable or at risk of deterioration
• Are experiencing a flare-up of a long-term condition
• Are showing early signs of decompensation or delirium
• Are declining inpatient care where a safe alternative is appropriate
• Are at high risk of readmission or have experienced frequent readmissions

Step-down referrals

Patients may be suitable if they:

• Are aged 65 or over with a Rockwood Frailty Score of 4-9
• Are clinically stable but require ongoing treatment that can be delivered at home
• Need continued monitoring of observations or blood tests
• Require consultant oversight while recovering
• Have improving infection or inflammatory markers that need monitoring
• Are recovering from an acute-on-chronic condition
• Need optimisation of treatment, including medication titration

How to refer

If you identify a patient who may be suitable for the Frailty Hospital at Home service, contact the team coordinator on:

07435 178 583

By considering Hospital at Home as part of discharge planning and admission avoidance, colleagues can help more patients receive the right care, in the right place, at the right time.