The Urgent Community Response (UCR) Frailty Service provides rapid, specialist care for acutely unwell frail patients in their own homes, helping to prevent unnecessary hospital admissions and the risks they can bring.
Delivered by our multidisciplinary clinical team, the service offers comprehensive assessment, personalised care planning and a range of advanced clinical interventions, enabling patients to receive the right care in familiar surroundings.
Working closely with ambulance services and community partners, the service also provides vital support for patients at the end of life, ensuring compassionate, coordinated care when it matters most.
The Urgent Community Response (UCR) Frailty Service provides rapid, home-based care for frail patients in the community, aiming to prevent unnecessary hospital admissions and reduce the risks associated with inpatient care. Hospital admission for frail patients carries increased risks, including falls, deconditioning, delirium, loss of independence, and healthcare-acquired infections. For many, admission can result in a permanent decline in functionality or the need for long-term care.
Referrals to the service are primarily made by ambulance crews and the JET community team through GPN’s Call Before Convey service. Patients must have a Clinical Frailty Score of 5 or above. The UCR team provides timely, targeted interventions in the patient’s home or via hot clinics in partnership with NWAngliaFT. Home-based care and clinics may include advanced clinical assessments, comprehensive geriatric assessment (CGA), observations, ECGs, blood tests with result review, wound care, prescriptions, imaging requests, and onward referrals. Standardised discharge letters, signed by the lead clinician, summarise findings and are shared with the patient’s GP practice to ensure continuity of care.
The UCR team is overseen by a GP or Senior Advanced Clinical Practitioner and includes Advanced Clinical Practitioners, Enhanced Practitioners, Urgent Care Practitioners, Paramedics, Urgent Care Technicians, and Health Care Assistants. The team can provide care and treatment for up to seven days before discharging patients back to their GP or other community services. All consultations are documented in SystmOne to ensure safe, coordinated care.
In addition to supporting frail patients with acute needs, the service provides critical support for patients at the end of life. This includes arranging essential medications, coordinating with community palliative teams, and working with the palliative care hub to ensure patient and family needs are met during times of crisis.
The Urgent Community Response (UCR) Frailty Service operates:
By delivering high-quality, rapid interventions in the patient’s home or community setting, the UCR Frailty Service prevents unnecessary hospital admissions, improves patient safety, supports independence, and ensures frail patients receive timely, patient-centred care.
Our urgent community frailty service supports eligible patients with complex health and care needs in the community.
Access to the service is through referral from an appropriate healthcare professional.
Patients cannot self-refer directly to the service.
If you or someone you care for may benefit from this service, please speak to the healthcare professional involved in your care.
They will assess your needs and arrange a referral where appropriate.
