Key findings

When older people have an unexpected hospital stay, they often lose some independence. Rehabilitation can help, but usual NHS rehabilitation only lasts 2-6 weeks. We wanted to see if extending the usual rehabilitation after hospital admission, could help older people after discharge home.

Between December 2017 and August 2021, 740 older people with frailty (aged 65 and over) took part in our research. Our 15 NHS trust sites approached people leaving hospital or intermediate care rehabilitation services following hospitalisation with illness or injury. We split participants into two groups randomly.

Everyone got their usual care from GPs and other care providers, but one group also got the exercise programme. We collected information from participants about their health, wellbeing and circumstances for 12 months. We compared the two groups to see if the group who received the exercise programme benefited from it.

The findings from the study saw that extending standard NHS rehabilitation is not recommended for all older people with frailty after an acute hospital admission. Read the summary poster and the main trial result publication for more information.


Background

Frailty is a condition that is common in older age. It develops because as we get older our bodies change, and can lose their inbuilt reserves. These changes mean that older people with frailty can experience sudden, dramatic changes in their health when they have an illness or injury. For example, an apparently minor illness such as an infection, or an injury such as a fracture, can cause an older person with frailty to become less mobile and unable to carry out day-to-day tasks. This can often result in admission to hospital, and a further period of immobility. This is a major problem because, in frailty, even short periods of immobility can cause muscles that are already weak to become even weaker, preventing movements such as getting out of a chair, getting out of bed, getting on and off the toilet and climbing stairs.

Older people with frailty are therefore likely to need a period of rehabilitation to improve overall muscle strength and ability to carry out day-to-day tasks before returning home from hospital. In the NHS, around a third of older people with frailty are likely to return home after a brief period of rehabilitation on a hospital ward. A further third will need a period of rehabilitation in ‘intermediate care’, which is a range of community rehabilitation services provided either in a setting such as a community hospital, or at home. However, current guidelines recommend that intermediate care should be for a relatively short period of between 2 to 6 weeks. A large national audit shows that people discharged from intermediate care often do not feel ready to leave the service and research suggests that the initial improvement from this short period of rehabilitation may not be sustained in the longer-term.

An important part of rehabilitation is progressive physical exercise. We have developed the Homebased Older People’s Exercise (HOPE) programme, which is a home-based exercise intervention for older people with frailty. Participants follow an exercise manual that contains exercises to strengthen the important muscles required for movements such as getting out of a chair, getting out of bed, and climbing stairs, under the guidance of a physiotherapist. The HOPE programme was developed with considerable input from older people with frailty, including the design of the exercise manual, to make sure that it is meaningful and acceptable to users. We have tested the HOPE programme with frail older people in a pilot clinical trial and the results show that the HOPE programme is feasible and safe, with potential to improve mobility.

The HERO trial answered a commissioned call from the NIHR. The trial studied the effectiveness of the HOPE programme as extended rehabilitation for older people living with frailty who have been discharged home from hospital (or from intermediate care) after illness or injury.

Aims & Objectives

Primary: To establish whether a home-based exercise intervention plus usual care as extended rehabilitation for older people with frailty improves health-related quality of life.

Secondary:

  • To establish whether the intervention improves mental health.
  • To establish whether the intervention improves activities of daily living.
  • To establish whether the intervention reduces hospitalisation rates, care home admission rates, falls and overall health and social care resource use.
  • To establish whether the intervention is cost-effective.
  • To understand how the intervention is experienced and understood by providers and recipients, and explore the organisational implications of embedding and sustaining the intervention in preparation for wider NHS roll-out.

Methods

Pragmatic multi-centre randomised controlled trial, including internal pilot with progression criteria and an embedded process evaluation and parallel cost-effectiveness analysis.

Population: Older people (aged >65) with frailty admitted to hospital following acute illness or injury then discharged home directly from hospital or from intermediate care services.

Intervention: 24 week home based exercise intervention (HOPE Programme).

The Hope Programme

The Home-based Older People’s Exercise (HOPE) programme is a home-based exercise intervention for older people with frailty. It is a 12 week graded, progressive exercise intervention aimed at improving strength, endurance and balance that is presented to participants in an exercise manual and delivered by community-based physiotherapists and therapy assistants. Participants will receive weekly support through five face-to-face home visits and seven telephone sessions. The programme will be extended with weekly telephone calls for a further 12 weeks to ensure that participants are well-positioned for ongoing self-management following completion of the intervention.

Outputs

Clegg A, Prescott M, Collinson M, Goodwin VA, Thompson E, Bestwick R, Bojke C, Clarke DJ, Day F, Forster A,  Hall AJ, Hulme C, Peacock J, Ziegler F, Farrin AJ. Home-Based Extended Rehabilitation For Older People With Frailty (HERO): A Randomised Controlled Trial. Age and Ageing, 2026;55(2). https://doi.org/10.1093/ageing/afag011

Prescott M, Collinson M, Hall AJ, Bestwick R, Goodwin VA, Thompson E, Bojke C, Clarke DJ, Day F, Forster A,  Hulme C, Peacock J, Ziegler F, Farrin AJ, Clegg A. Home-Based Extended Rehabilitation For Older People With Frailty (HERO): A Multicentre Randomised Controlled Trial With Health Economic Analysis And Process Evaluation. Health Technology Assessment, 2026;30(4):1-40. https://doi.org/10.3310/GJAC1602

Hall AJ, Ziegler F, Prescott M, Goodwin VA, Hulme C, Farrin AJ, Thompson E, Forster A, Clegg A, Clarke DJ. Process Evaluation Exploring Implementation And Delivery Of A Home-Based Extended Exercise Intervention For Older People With Frailty: The HERO Trial. Health Technology Assessment, 2026;30(4): 41-66. https://doi.org/10.3310/GJAC2501

Clegg A, Prescott M, Collinson M, Goodwin VA, Thompson E, Bestwick R, Bojke C, Clarke DJ, Day F, Forster A, Hall A, Hulme C, Peacock J, Ziegler F, Farrin AJ. Home-Based Extended Rehabilitation For Older People With Frailty (HERO): A Randomised Controlled Trial. MedRxiv [Preprint] 2025. https://doi.org/10.1101/2025.06.17.25329580

Prescott M, Lilley-Kelly A, Cundill B, Clarke D, Drake S, Farrin AJ, Forster A, Goodwin M, Goodwin VA, Hall AJ, Hartley S, Holland M, Hulme C, Nikolova S, Parker C, Wright P, Ziegler F, Clegg A. Home-Based Extended Rehabilitation For Older People (HERO): Study Protocol For An Individually Randomised Controlled Multi-Centre Trial To Determine The Clinical And Cost-Effectiveness Of A Home-Based Exercise Intervention For Older People With Frailty As Extended Rehabilitation Following Acute Illness Or Injury Including Embedded Process Evaluation. Trials 2021;22(783). https://doi.org/10.1186/s13063-021-05778-5

Hall AJ, Nikolova S, Prescott M, Goodwin VA. Older People’s Perception Of Being Frail – A Qualitative Exploration. BMC Geriatrics 2024; 24: 453. https://doi.org/10.1186/s12877-024-05079-x

Hall AJ, Goodwin VA, Clarke DJ. Fidelity, Pragmatism And The “Grey Line” In Between – Exploring The Delivery Of A Pragmatic Physical Activity Randomised Controlled Trial – A Secondary Analysis. BMC Medical Research Methodology 2024; 24: 118. https://doi.org/10.1186/s12874-024-02242-1

Clegg A, Barber S, Young G, Iliffe S, Forster A. The Home-Based Older People’s Exercise (HOPE) Trial: A Pilot Randomised Controlled Trial Of A Home-Based Exercise Intervention For Older People With Frailty. Age and Aging 2014; 43: 687-695. https://doi.org/10.1093/ageing/afu033

Media

HERO Results Poster Open PDF
HERO Participants Thank You Card Open PDF

Partners & Collaborators

Investigators

Professor Andrew Clegg, Dr David Clarke, Bonnie Cundill, Professor Amanda Farrin, Professor Anne Forster, Professor Vicki Goodwin, Suzanne Hartley, Professor Claire Hulme, Phil Wright, Professor John Young.

Collaborators

Academic Unit of Elderly Care and Rehabilitation, University of Leeds.
Bradford Institute of Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust.
Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds.
Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds.
University of Exeter Medical School.

Timescales

01/03/2017 – 31/05/2023

Funding agency

National Institute for Health and Care Research (NIHR)

Further information

For further information please contact Project Lead Professor Andrew Clegg or Trial Manager Matthew Prescott Tel: 01274 383424

This summary presents independent research funded by the National Institute for Health and Care Research Health Technology Assessment Programme (NIHR HTA)  (Grant Reference Number: 15/43/07). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Ethical Approval:

Yorkshire & The Humber – Bradford Leeds Research Ethics Committee (REC Reference 17/YH/0097).

Trial Registry:

ISRCTN Registry: 13927531 https://doi.org/10.1186/ISRCTN13927531