What is the Proactive Care Framework?
According to NHS England, proactive care is defined as:
“Personalised and co-ordinated multi-professional support and interventions for people living with complex needs.”
Its aims include:
- Delaying health deterioration
- Maintaining independent living
- Reducing avoidable exacerbations and unplanned care
This framework is particularly focused on people living at home with moderate or severe frailty, and it promotes a biopsychosocial approach—addressing physical, psychological, and social needs in a timely, person-centred way
The Five Pillars of Proactive Care
Locally within Gloucestershire ICB, the framework has been adapted and structured around five key pillars.
The 5 Pillars of Proactive Care
What is the Proactive Care Framework?
According to NHS England, proactive care is defined as:
“Personalised and co-ordinated multi-professional support and interventions for people living with complex needs.”
Its aims include:
- Delaying health deterioration
- Maintaining independent living
- Reducing avoidable exacerbations and unplanned care
This framework is particularly focused on people living at home with moderate or severe frailty, and it promotes a biopsychosocial approach—addressing physical, psychological, and social needs in a timely, person-centred way
Locally within Gloucestershire ICB, the framework has been adapted and structured around five key pillars.
The 5 Pillars of Proactive Care
- Case Identification
- Identify individuals at risk of deterioration or with multiple conditions.
- Use data a data driven approach to identify people who may benefit from a proactive care approach
- Tools to use: the Personalised Proactive Whiteboard (PPW)
- Holistic Assessment
- Carry out holistic assessments that consider the whole person and the impact of the wider determinants of health
- Use shared decision making principles
- Tools to use:
–The red flag tool
-Personalised Care approach
–The Comprehensive Geriatric assessment
-Falls risk assessment
-Assessment of cognition
3. Personalised Care & Support Planning
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- Develop a goal oriented personalised care and support plan based on ‘what matters to me’ conversations
- Tools to use:
– Me at My Best
– Personalised outcome measures e.g MYCaW
4. Coordinated & multi-professional working
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- Deliver coordinated multi-agency/multi-professional interventions and support to address the person’s range of needs
- Ensure a single point of contact for individuals and carers
- Tools to use: Community- based rehabilitation/reconditioning classes
– Community- based rehabilitation/reconditioning classes
-Structured medication review and management
-Nutritional screening/education and advice
-Care and support
-Aids and adaptation, housing
-Access to local community support
-Digital Care Plan (JUYI)
-MDT approach to plan and coordinate care
5.Continuity of Care
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- Provide a clear plan for continuity of care, including an agreed schedule of follow ups and future review
- Tools to use:
-Information, advice and guidance
-Multi-agency, multi-disciplinary discussions
Resources: