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What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

Our acute trust provided care within Cornwall for very ill patients during the Covid-19 pandemic. In order to support this 3 Community Assessment and Treatment Units were created to enable frail elderly people to be cared for closer to home encompassing the ethos of Placed Based Care.

The 3 units and one Opel unit are within smaller hospital units closer to the community in which they serve.

Frail elderly people we know have multiple comorbidities and often need the support of review of a specialist.

Our ambition is to be able to provide remote connections to specialists so that a consultation can take place and a plan can be formulated rather than divert the person to a busy emergency department. If we can achieve the best we can deliver then a remote consultation may reduce the number of frail elderly people having to be escalated to the acute trust for a consultation

What does your project aim to achieve?

We will achieve an innovative IT solution that will enable complex medical and surgical decisions to be made remotely.

We want to see if this innovation prevents unnecessary transfers to acute facilities, as well as promoting a rapid assessment and transfer to the most appropriate setting for frail elderly people.

We will support our workforce in adopting and feeling confident in delivering and taking part in remote consultations, using the best technological systems available to the NHS.

Out outcomes will be based on

1. Patient satisfaction

2. Best Outcomes for our people and our staff

3. A reduction in unnecessary transfers and escalations, including a reduction of patient safety incidents

4. Innovation in how we could adopt and use technological solutions

5. Workforce Education and Training in using technological solutions within a Community Hospital Setting

6. Best use of Emergency Services in relation to Transportation

7. Cost efficiencies

How will the project be delivered?

We know that during Covid-19 the resources within our acute organisations were needed to provide highly complex and invasive support to people suffering the complications of Covid-19

Thinking differently we adopted a new approach in how we care for and deliver services closer to home for our frail elderly people.

The skills and competencies within our community hospital services were under used and not really fully recognised or utilised.

Adopting a transformational  methodology we will adopt a test and learn approach

Providing bespoke training and education around the technological solutions we can adopt and learn from

Measuring the impact of

1. Patient satisfaction and outcomes

2. Can we identify a better patient and staff experience

3. Reduce unnecessary travel often out of hours and then a long wait in a busy Emergency Department that can be disorientating and cause more anxiety to someone who may already have a delirium or a dementia

How is your project going to share learning?

Shared learning across the Health and Social Care system within the South West and Q Members

Formulate a research study and publish findings

The potential of this proposal is very exciting, its demonstrating how acute and community services can work collaboratively to provide the very best care we can during a national pandemic.

Removing professional boundaries has the potential to support the system to transform as we should within a placed based care arena working in partnership with multiple specialities and professionals in a  hope that we can provide a better outcome for our frail elderly people who often become stuck within a system of sophisticated models of care. This project has the potential to transform Frailty Care, decrease patient safety incidents and to set it within our community where people wish to be cared for.

How you can contribute

  • :We would like to ask if any other member has achieved remote consultations that provide best practice to enable a highly complex clinical decision to be made in order to support frail elderly people who often have multiple comorbidities
  • : Are there sophisticated remote video consultation software packages already supporting this type of
  • : Does this transformation prevent frail elderly people to have better outcomes
  • : How could we support peoples wishes at a time that they may be approaching EOL care

Plan timeline

28 Feb 2021 Establish Roles set project timelines and outcome dates
31 Mar 2021 Launch project scope solutions test and learn phase
31 Jul 2021 Evaluate solution and impact
30 Sep 2021 Roll out transformation


  1. Hi Sue,

    Thank you for sharing this work at The Community Hospital Frailty Forum last week.

    It will be really important to be able to measure the outcomes you have highlighted. Will part of your outcome be to measure whether interventions such as diagnostics have increased or decreased in your units as this could be important in terms of informing frailty pathways?

    Good luck with this, as we saw at the forum, this is work other areas arte keen to tap and learn from.

    Within the Hospice, we have used AccuRx to link a CNS doing a home visit to a neurologist which allowed a 3 way consultation. This is a tool supported by the NHS. Worked brilliantly and we are looking at whether we can build it's use into our MND patient pathway.


  2. Is there anyone out there who is excited to work with us Our initial outcomes have been amazing and we want to take this forward so we can continue to improve the care we provide to frail elderly people. This project has such great potential.

  3. An excellent initiative. A challenge to provide care close to home whilst maintaining access to specialist input. Learning from others- I was impressed to learn about the links between community hospitals and the acute hospital in Aberdeen regarding MIU and A/E. Quite a long time ago but this article sets it out.



    1. Thank you I've shared with our team members. Sue

  4. Great Project- will put send an appointment as we have access to some packages that may be useful from within Digital Health Services.

  5. This looks like a great way to build on the work already done. Happy to share via CHA Sue.




    1. Yes please Evelyn

    2. Yes please Evelyn that would really help.

  6. Guest

    Frazer Underwood 1 year ago

    This brilliant project is crying our to find a collaboration partner to share learning from in the adoption of technology to transform the early assessment of older peoples living with frailty close to their homes. Rapidly co-ordinating the expert assessment outcomes of the multiprofessional team will have a significant impact of the health outcomes of older people needing urgent care.

    Is there anyone out there who we could collaborate with?

    1. Are there any budding technicians who would be willing to work with us. The CATU is a great success so far and we have been able to keep our people closer to home, our aim is to try now and limit unnecessary transfers where ever we can. In doing this we will be better in how we support our frail people and also assist keeping people out of really busy acute settings which is going to be key over the next 12 months.

      Has anyone been successful in connecting remotely from Community Hospital settings to specialists within the acute sector and how did you do this were you able to provide a robust and quality assessments of a persons condition and needs

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