Be proactive: Delivering proactive care - Chapter four: Conclusions, Appendices & References

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British Geriatrics Society
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Primary and Community Care
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Health and social care policy
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This publication outlines how to deliver proactive care against core components and key enablers, acting as a roadmap for implementing the NHS England framework and delivering proactive care services. This final chapter provides a conclusion, as well as appendices, including case studies of successfully implemented proactive care services.

Conclusion

With population ageing and older people living for longer periods with frailty, there is an increasing need for proactive care interventions to target older people with moderate and severe frailty to ensure they live well and stay independent for as long as possible.

Proactive care aims to be a cost saving approach which incorporates tailored and targeted interventions to ensure that the onset of poor health is delayed, individuals maintain independence, avoidable period of ill health are reduced, and older people enjoy healthier lives in the way the matters most to them. This prevents avoidable hospital admissions or readmissions, reduces length of stay in hospitals, and reduces the need for social care. It should be embedded across all community and primary care settings, and Co-ordinated funding and contracting is needed to ensure this becomes a reality. 
 

Appendix 1: Examples of existing proactive care services  

The BGS has collected a list of case studies from our members across the UK, illustrating existing examples of proactive care services in primary and community settings. The full list of case studies can be found here. The table below is intended to be guide for users to navigate to sample case studies of interest, depending on setting, pathway, and the type of advice sought. 

 

Setting

Name

Pathway

Does the case study include the voice of patients and staff?

What were the main lesson learnt?

What does the case study illustrate?

One Primary Care Network

Sport in confidence

Led by one Occupational Therapist (OT) funded through Additional Roles Reimbursement Scheme. The OT leads on proactive frailty assessments and interventions.

The case study includes patient stories.

  • Patients were new to the idea that OTs can have an impact on patient function.
  • How to Identify and support leaders
  • How to decide on how to measure outcomes
  • How to agree on process evaluation
  • How to develop relationships with local services

Single GP practice

Caddington Surgery

Team wide recognition of people with frailty needing assessment and management of long-term conditions. The service uses ARRS-funded roles.

The case study includes patient stories and quotes from staff.

  • Ringfenced time enables proactive care to work.
  • Treating frailty like a long-term condition with recall is easier for GPs to manage.
  • How to agree processes for assessment
  • How to implement continuity with regular recall
  • How to develop relationships with local services

Two Primary Care Networks

North Devon Anticipatory Care

MDT based proactive frailty assessment and intervention. It was a GP initiated community services collaboration which spread to a second PCN.

The case study includes quotes from patients and staff.

  • Keep case identification simple.
  • Structure the MDT to be time efficient and a learning place.
  • Keep “what matters most” to older person at the heart of proactive care plans.
  • How to enable a workforce with mindset and skills to deliver proactive care
  • How to decide how to measure outcomes at start of service
  • How to allow the development of the service using feedback.

 

 

Primary Care Network and Community NHS Foundation Trust collaboration

Moreton and Meols PCN and Wirral Community NHS Foundation Trust

Shared PCN and community trust core team assess and follow up with patients with frailty identified through referrals and data searches.

The case study includes quotes from patients and staff.

  • Pooling staff resource from the community trust and the PCN to look after patients with complex needs reduces rather than increases staff workload.
  • Proactive care improves staff experience.
  • The service enables the team to work better together.
  • The service removes referral barriers and enables sharing of records.
  • Case identification by referral augmented by monthly data searches fills the team’s capacity.
  • Patient tracker tools enable follow up.
  • Feedback to GP surgeries demonstrates value.
  • That proactive care services should be aligned to the approximate geography of a PCN /cluster.
  • Trust and relationships are at the core of proactive care.
  • How to agree core team membership and infrastructure.
  • How to access information sharing.
  • How to agree process and plan for continuity and follow ups.

One Primary Care Network

Hatters Health

Clinical Director initiated community trust collaboration operating across one PCN. Patients are identified through birthday card over 75 checks, proactive housebound frailty checks. It involves collaborative dementia support.

The case study includes quotes from patients and staff.

  • Equip healthcare professionals to use the holistic 5M 5Q assessment tool. This helps people to understand frailty in the wider psychosocial context and identify ‘whole person needs’
  • Documentation using the 5 Ms tool helps to share a simple summary of patient needs and proactive care planning decisions with other professionals. Share this by enhancing the summary care record.
  • How to agree processes for assessment
  • How to train and develop staff
  • How to upskill care co coordinators
  • How to develop a relationship with local services and resources

GP led collaboration with community services and acute trust.

Islington PAWS

System wide (acute, community, primary care) involving CFS screening for moderate frailty for proactive care.

The case study includes a case story and quotes from staff.

  • Offer earlier interventions for patients.
  • Collaboration is rewarding for staff, and it reduces duplication.
  • How to get clarity on the aim of service and develop shared values
  • How to promote proactive care and engage senior leader support
  • How to share IT
  • How to identify a cohort

One Primary Care Network

The PACT service, WISHH and 5 Lane Ends PCN

Initiated by a community partnership (prior to PCN formation), which continued when PCN formed using ARRS funded roles. Individuals are identified through GP referrals and data. Home assessments are completed by upskilled care coordinators, followed by MDT review.

 
  • Spread ideas to other PCNs locally.
  • Work on evaluation and QI.
  • How to interact with the wider MDT.
  • Importance of training and development.
  • Allowing the service to develop over time using QI

Acute trust and single Primary Care Network collaboration

Keeping Well Dunstable Hub

The initiative is based in a newly built hub led by geriatricians. Care coordinators identify GP patients likely to benefit form holistic assessment and intervention.

The case study includes staff and patients quotes.

  • The personalised patient care plans can include access number to virtual ward.
  • Strength and balance classes running alongside the clinic allow group learning for home exercises.

 
  • How to promote proactive care and engage senior leader support.
  • How to facilitate information sharing.
  • How to develop relationships with local services.

Three Complex Care Teams (CCTs) aligning with three Primary Care Networks

South Somerset Complex Care Team

CCTs consists of a GP, senior nurse, and band 4 support key worker aligning to a PCN. They provide comprehensive assessments of complex patients, coordination and information sharing with GPs, community teams, and secondary care hospital team.

 
  • CCTs are committed to breaking down barriers to care, always instilling a mentality of ‘what can we do to help?’, while always remembering that ‘There is a patient (family/carer) at the centre of every decision’.
  • Spread skills for frailty and complex care for the future by offering training placements for Advanced Care Practitioners and Foundation Year 2 doctors
  • How to instil a workforce with the mindset and skills for delivering proactive care.
  • Importance of training and development.
  • Trust and relationships are at the core of proactive care.
  • Regular wider MDT meeting is important.
  • How to promote the service.

Three integrated hubs (each aligned with three PCNs)

The North West Surrey Locality hub service

Integrated MDT in three hubs receives referrals from any local health or social care professional within North West Surrey. Patients have to have a clinical frailty score of 4-8 and aged over 65. The hubs provide assessment, signposting, carer support, and follow up.

The case study includes quotes from patients and carers
  • Over time, experiencing the benefits of a proactive frailty service and collaborative working changes siloed cultures and mindsets.
  • How to promote proactive care and establish senior leader support.
  • How to establish a core team
  • How to access information sharing
  • How to develop relationships with local services

 

Two Primary Care Networks

Frimley

Population health data is used to identify a cohort for frailty assessments by the MDT. Initially a geriatrician-initiated project in one PCN, which spread to two PCNs.

The case study includes quotes.

  • Patients do not like the term “frailty”
  • Face to face assessment and “what matters most” discussions with patients vital before an MDT discussion.
  • Importance of a workforce with mindset and skills for delivering proactive care.
  • How to establish clarity on the aim of the service and shared values
  • How to identify the cohort
  • How to access to information sharing
  • Importance of setting realistic expectations
  • How to start small and take stock local resources.

One integrated care centre covering 15 PCNs.

Jean Bishop Centre

Patients are referred to the centre which provides a comprehensive assessment from the MDT.

 
  • Patients report sustained improvement in emotional and physical wellbeing.
  • System benefits include reduction in unnecessary presentations to emergency departments, reduction in ambulance conveyances and saving GP clinic time.
  • Leadership for proactive care should be supported and nurtured.
  • How a culture of proactive care can grow.
  • Community geriatrician leadership enabled MDT culture growth.
  • How to develop relationships with local services.

Four GP Practices in collaboration with a local charity

Lanarkshire

MDT approach identifying patients through eFI and team knowledge to offer a holistic needs assessment to produce a care plan.

 
  • Interventions had an impact on social care and rehabilitation referrals.
  • Assessments by third sector partners were a positive experience for patients.
  • How to develop relationship with local services.
  • How to develop a effective multidisciplinary working.

Appendix 2: Roadmap for setting up a proactive care service

References

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Contributors

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  • Dr Lloyd Hughes, GP Partner, Tayview Medical Practice; and GP Lead for Primary and Preventative Care for Rehabilitation and Forensic Psychiatry, Stratheden Hospital, NHS Fife
  • Dr Tara Verity, Portfolio GP with Special Interest in Frailty, Central Bedfordshire
  • Dr Deb Gompertz, BGS Deputy Honorary Secretary; and Complex Care GP, South Somerset
  • Dr Liz Lawn, BGS Honorary Treasurer; and retired GP
  • Lucy Aldridge, BGS Policy Co-ordinator

With our thanks to the following BGS members who took part in three advisory board meetings to inform the content of this report:

  • Dr Lucy Abbott, Consultant Geriatrician and Chief of Service for Community Services and Older Peoples Medicine,  Frimley Park Hospital; and NHS England South East Regional Clinical Advisor for Frailty 
  • Dr David Attwood,  Associate Medical Director, Livewell Southwest; Chair of the Healthy Ageing Programme Board, NHS Devon; and GP with Special Interest in Older People, Pathfields Medical Group.  
  • Dr Michael Azad, Consultant Geriatrician, Nottingham University Hospitals NHS Trust.
  • Dr Eileen Burns, Former BGS President; and Former NHS England National Specialty Advisor.
  • Anne Child, Pharmacy and Dementia Specialist Lead, Dementia Care Mapper.
  • Emily Harrison, Senior Specialist Pharmacist and Independent Prescriber in Elderly Care and Frailty, Dorset County Hospital NHS Foundation Trust.
  • Dr Adrian Hayter, Medical Director, Royal College of General Practitioners; and GP, Runnymede Medical Practice.
  • Professor Anne Hendry, Senior Associate, International Foundation for Integrated Care (IFIC); Honorary Professor, University of the West of Scotland; Honorary Physician, NHS Lanarkshire Research and Development Department.
  • Dr Rod Kersh, Consultant Community Physician, Partner, Manor Field Surgery, Maltby; and Divisional Director Therapies, Dietetics and Community Care, Rotherham NHS Foundation Trust.
  • Dr Tessa Lewis, Locum GP, Wales.
  • Aileen McCartney, Advanced Clinical Practitioner in Frailty, Whitstable Medical Practice.
  • Claire Norman, Advanced Nurse Practitioner and Frailty Lead, Victoria Road Surgery, Worthing. 
  • Dr Marianne Plater, Community Geriatrician, Lymington New Forest Hospital.
  • Dr Joanna Seeley, Specialist Doctor,  East Kent Frailty and Home Treatment Service.
  • Michael Smith, Specialist Nurse for the Older Adult, Market Rasen Surgery.
  • Dr Jennifer Sutton, Project Lead (Council for Allied Health Professions Research), Royal College of Occupational Therapists.
  • Dr Ana Talbot, Consultant in Medicine for Older Adults,  University Hospitals Monklands; and Honorary Senior Clinical Lecturer, University of Glasgow.
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