The DHB is also rolling out a clinical pharmacist programme to help with complex medications.
The community-based Enliven and an interdisciplinary rapid response team based in the Hawke's Bay Emergency Department provide early-intervention for frail people at risk of admission to aged residential care or hospital.
At the same time, district nurses have been working with two Hastings general practices to better integrate their services.
In 2013, three Intermediate Care beds were established at the Atawhai Aged Care facility, overseen by GPs in partnership with the geriatrician.
Both models led to improved outcomes "unachievable with past ways of working" a report by the Integrated Care Services general manager Kieran McCann said.
The roll out to clusters of general practices in Napier and Hastings aligns with the DHB's strategy of shifting care out of hospitals into communities.
Rural areas will be rolled out at a later date because they need to align with their integrated family health centre developments.
While Hawke's Bay's population is expected to grow by just 3.9 per cent over the next 10 years, the number of people older than 65 is expected to grow by 47 per cent and people over 85 by 45.5 per cent.
Another 72 hospital beds would be needed for acute care under the current care model.
"Alternative solutions need to be put in place urgently to manage the health care for the growing numbers of people over 85 years from 2015 onwards," Mr McCann said.
The report said most people over 85 lived well and longer if supported in their own homes.
