The Cambridge University Hospitals NHS Foundation Trust (CUH) has rolled out an initiative across Cambridgeshire that places hospital geriatricians and multi‑disciplinary teams directly into care homes to provide assessments, clinical support and ongoing treatment.
Care at home for complex needs
At Heathlands House Care Home in Cambridge residents are now being seen in person by hospital doctors as part of the Enhanced Reviews in Care Homes (EnRICH) service. The scheme brings together hospital geriatricians, community nurses, pharmacists, care‑home staff and local GPs to manage frail older people’s care within their usual surroundings.
One beneficiary is Clifford Craske, aged 96, who has multiple long‑term conditions including dementia, heart failure, diabetes, chronic obstructive pulmonary disease (COPD) and a history of stroke. According to CUH, in the year before EnRICH began at his home he was admitted to hospital three times; since the service started he has received specialist input in the care home and been kept out of hospital.
“For him, it is very traumatic. As soon as he was in the hospital he didn't want to stay… By him being treated here, within the care home, it is much more settling for him,”
The comment came from his daughter, who is a retired nurse and says the scheme has created a closer working relationship between GPs and hospital consultants and has helped prevent hospital admissions for her father.
How EnRICH works
CUH clinicians describe EnRICH as a co‑ordinated approach to managing frailty and complex health needs at the place residents call home. Teams typically visit care homes in person — in some instances arriving by bicycle — to carry out assessments and advise on treatment plans alongside care‑home staff.
- Hospital geriatricians provide specialist assessment and management for older people.
- Community nurses and pharmacists support medication review and on‑site care.
- Care‑home staff and GPs collaborate to reduce unnecessary hospital transfers.
The model aims to reduce distress for residents who find hospital admission traumatic, improve continuity of care and lower the risk of avoidable readmissions.
Example: one resident's pathway
| Metric | Before EnRICH | After EnRICH |
|---|---|---|
| Hospital admissions (example resident) | 3 in one year | None reported since service began |
| Primary conditions | Dementia, heart failure, diabetes, COPD, prior stroke | |
Local families have welcomed the changes, saying treatment at the care home is less disorientating for relatives with cognitive impairment and helps preserve residents’ sense of home.
CUH has published research in the journal Age and Ageing related to the approach, and clinicians say bringing specialist expertise into care homes can strengthen links between primary and secondary care services. The trust is rolling the programme out across more sites in Cambridgeshire as part of efforts to improve care for older adults and reduce pressure on hospital beds.
For families and care homes seeking further information, contact details for local services and GP practices remain the primary route for referrals, and care homes can liaise with CUH to request EnRICH team input where available.
