Vulnerable Adults
Supporting vulnerable adults to live well, safely and independently
DDHF’s services for Vulnerable Adults provide compassionate and coordinated responsive and preventative care for patients who are at greater risk of hospital admission or deteriorating health.
Working across care homes, GP practices, and local communities, our multidisciplinary teams help patients remain in their preferred place of care for as long as possible - improving quality of life, supporting independence, and reducing avoidable hospital admissions.
Our services combine clinical expertise, personalised care planning, and strong partnership working to deliver responsive support for some of the most vulnerable people across Durham Dales.
A Proactive and Integrated Model of Care.
Our Vulnerable Adults model brings together:
- Enhanced Health in Care Homes (EHiCH) delivery on behalf of local Primary Care Networks (PCNs)
- Proactive community-based frailty support
- Urgent clinical assessment and intervention
- Personalised care and advanced care planning
- Multi-disciplinary collaboration across health and social care services
By integrating services across primary care and community settings, we help ensure patients receive joined-up, consistent, and person-centred care.
Specialist Teams Delivering Expert Care
The service is led by experienced nurses and supported by a highly skilled multidisciplinary workforce including:
- Advanced Nurse Practitioners (ANPs)
- Nursing Associates
- Health Care Coordinators
- Emergency Care Practitioners
Health Care Coordinators also play a vital role in delivering:
- EHiCH ward rounds
- Personalised Care Support Plans
- Ongoing coordination between services and care providers
Delivering Measurable Impact
During 2024/25, DDHF’s Vulnerable Adults Services delivered significant support across the region.
Vulnerable Adults Wrap Around Service (VAWAS)
telephone triage contacts
care home visits
community visits
Enhanced Health in Care Homes (EHiCH)
ward round patient contacts
Personalised Care Support Plans completed
These services have achieved a significant reduction in avoidable admissions from care homes, supporting safer and more effective care closer to home.
Enhanced Health in Care Homes (EHiCH)
DDHF works closely with more than 20 care homes and all 12 member GP practices across Durham Dales to provide enhanced clinical support for residents living in care settings.
Our clinicians often act as the first point of contact when care home residents require assessment or treatment for acute or chronic health conditions.
Working collaboratively with care home staff and GP practices, we provide:
- Clinical assessments and treatment
- Ongoing monitoring and review
- Medication support
- Emergency care planning
- Preventative interventions
- Regular multidisciplinary ward rounds
A shared medical record system ensures everyone involved in a patient’s care has access to consistent, up-to-date information.
Personalised Care That Respects Patient Wishes
A key focus of the service is ensuring care reflects the wishes, preferences, and dignity of patients.
Our teams support the development of:
- Personalised Care Support Plans (PCSPs)
- Emergency Health Care Plans (EHCPs)
Frailty@Home — Proactive Support in the Community
Launched in 2025, Frailty@Home provides proactive support for moderately and severely frail patients living in the community across Teesdale, Wear Valley, and Bishop Auckland PCNs.
Built around the British Geriatrics Society “Be Proactive” guidance, the service focuses on helping vulnerable adults remain independent at home for longer.
The team supports patients who may be:
- Living with moderate or severe frailty
- Aged 65+
- Housebound
- Living with dementia or COPD
- Frequently attending hospital services
Working closely with GP practices, the Frailty Team identifies patients who may benefit from proactive intervention and delivers personalised support focused on:
- Prevention and early intervention
- Medication reviews
- Advanced care planning
- Holistic wellbeing support
Reducing Hospital Admissions Through Prevention
Our Pharmacy Team works collaboratively with GP practices every day to provide expert clinical support and reduce pressure on frontline services.
Everything we do is designed to prevent deterioration before a crisis occurs.
By providing proactive monitoring, rapid clinical support, coordinated care planning, and strong partnership working, DDHF’s Vulnerable Adults Services help:
- Reduce unnecessary hospital admissions
- Support safer care in the community
- Improve patient experience and dignity
- Provide reassurance for families and carers
- Strengthen continuity of care across services
Caring for our most Vulnerable Communities
DDHF’s services for Vulnerable Adults are built around compassion, prevention, and partnership.
Through proactive care, multidisciplinary collaboration, and personalised support, we are helping vulnerable adults across Durham Dales live healthier, safer, and more independent lives in the place they call home.