Proactive care can help people to remain living independently and well for as long as possible in the place they call home. It plays a vital role in addressing health inequalities.

Early intervention coupled with targeted support can delay deterioration and reduce avoidable exacerbations of ill health. This in turn can help to avoid the use of unplanned care, with its associated costs, which can often result in an irreversible loss of strength and fitness.

Proactive care can also mean that as someone enters their last phase of life, the individual has their needs and wishes documented, meaning they are more likely to experience a ‘good’ death, in the place of their choosing.

British Geriatric Society: Be Proactive: Evidence supporting proactive care for older people with frailty.

According to NHS England, proactive care is defined as:

“Personalised and co-ordinated multi-professional support and interventions for people living with complex needs.”

“Proactive care plays a vital role in delaying the onset of frailty, maintaining older people’s independence, and reducing avoidable periods of ill health”

Proactive care can:

  • Delay health deterioration
  • Maintain independent living
  • Reduce avoidable exacerbations and unplanned care

The NHS England Proactive Care Framework focuses on the health and wellbeing of people living at home with moderate or severe frailty. It promotes a biopsychosocial approach which means addressing physical, psychological, and social needs in a timely, person-centred way.

Proactive care provides personalised care which means people have choice and control over the way their care is planned and delivered. It is based on ‘what matters’ to them and their individual strengths and needs.

NHS England » Proactive care: providing care and support for people living at home with moderate or severe frailty

‘I’ statements share the perspective of those who receive proactive care to ensure that care is person-centred. In places these also include ‘I’ statements relating to palliative and end of life care.

These are developed by National Voices, are advocated by the Care Quality Commission, and can also be found in the British Geriatric Society publication Be Proactive: Evidence supporting proactive care for older people with frailty. and ambitions-for-palliative-and-end-of-life-care-2nd-edition.pdf

1. Case Identification

“I am identified as someone who may benefit from proactive care and am invited to have an assessment of my needs.”

“I am provided with clear and accessible information, tailored to my needs, about what proactive care is and the potential benefits. I understand why I have been identified and what I can expect from the holistic assessment. I feel I am able to decide if I want to accept the proactive care offer.”

“I am asked about my requirements and preferences for the holistic assessment, such as who I might want to have with me at the assessment. I can ask any questions I may have.”
  • Use data driven approach to systematically identify people who may benefit from a proactive care approach. This will help identify those people who have not already come to the attention of health and care services.
  • Identify individuals at risk of deterioration or with living with frailty .
  • Tools to use:

2. Holistic Assessment

“I meet with a professional who works in health or care to discuss my physical and mental health, social and self-care needs and how they impact my life.”

“Depending on my needs, be invited to have further assessments with other professionals. I can have family members, friend, carer or advocate with me during the assessment.”

“I can consider, explore and share with others who, and what, matters most to me in my life and how this might change if I were to become less well. I feel confident that I have gained more control of my own life through doing this.”

A holistic assessment is the first step in building a relationship with the individual, their family and any unpaid carers. Building trust will be the foundation for the personalised care and support plan that follows.

A multi-agency, multi-disciplinary approach may be needed to ensure that a holistic assessment is person-centred and consider the individual’s physical, psychological, spiritual and social needs. The assessment is needed to inform the subsequent development of a personalised proactive care plan. The assessment reflects “what matters to me” and provides a baseline for the individual.

A holistic assessment, including when planning for the last phase of life, can ensure that all aspects of a person’s wellbeing, including physical, social and spiritual, are addressed comprehensively to enhance quality of life.

A multi-disciplinary approach to Comprehensive Geriatric Assessments with individuals, and their carers, means that the full range of health, social and self-care needs are considered and as a result inform plans to prevent deterioration and promote independence.

  • Carry out holistic assessments that consider the whole person and the impact of the wider determinants of health
  • Use shared decision-making principles
  • Consider other assessments such as:
    • Mental capacity
    • assessment under the Care Act 2014
    • carer assessment and a carer support plan
Tools and Resources–The red flag tool: The red flag tool was originally created for people living with dementia (PLWD). These red flags are for deterioration in dementia and/or a need for increased support/MDT discussion to plan and support the individual. 

–The Comprehensive Geriatric assessment

-Falls risk assessment (in development)

–Delirium screening

–Carers assessment

–Interventions Framework 

3. Personalised Care & Support Planning

“I have a conversation with a professional who works in health or social care about what matters to me in my life and what would make my life better. Together we develop a plan about the things that are important to me, my needs and my aspirations.”“I am given all the information I need in advance to prepare for this conversation and in a way that I understand. This includes information about any legal rights I might have. I can choose who I would like to be involved in the planning discussion, for example, a family member, carer, advocate or interpreter.”

“I can access and share my plan whenever and with whomever I choose, and it can be updated whenever my circumstances change.”

“My plan is also shared with professionals who are involved in my care to make sure they that they understand who I am and how I want to live my life.”

“When developing my plan, I feel heard, and my culture and identity are understood and respected. I am empowered to speak honestly about what matters to me and the support I need and want to manage my health.”

“I and the people important to me, have opportunities to have honest, informed and timely conversations and to know that I might die soon. I am asked what matters most to me. Those who care for me know that and work with me to do what’s possible.”

Co-produce  a goal-oriented personalised care and support plan based on ‘what matters to me’ conversations.

Co-producing a personalised care and support plan ensures it is tailored to what matters most to the person. This helps them feel more supported to understand how to make changes to improve their self-care and wellbeing.

For someone with multiple or complex health and care needs, a personalised care and support plan means that their care is coordinated and joined up. So as not to overwhelm the person and to make the plan feasible, interventions should be prioritised based on their potential impact and people’s preferences.

If someone cannot express their wishes, these are recorded and so that family and staff know what is important and can act in their best interests.

A range of evidence-based interventions and support should be considered as part of co-developing the personalised care and support plan. These interventions and support may need to be prioritised or sequenced for maximum impact.

Tools and resources:

4. Coordinated & multi-professional working

“After I have had my holistic assessment and developed my personalised care and support plan, a team of professionals who form a multidisciplinary team (MDT) meet to discuss my needs and make recommendations about what might help me to meet my aspirations.”“It will be possible for me to attend the MDT meeting should I wish to, but if I am unable to, I know that my views will be presented, and I will be provided with clear information about the discussion. I also know that the discussion is to make recommendations for me rather than decisions about me and that I am in control of my care.”

I get the right help at the right time from the right people. I have a team around me who know my needs and my plans and work together to help me achieve them.

“I can make the last stage of my life as good as possible because everyone works together confidently, honestly and consistently to help me and the people who are important to me, including my carer(s)”

Deliver coordinated multi-professional interventions and support to address the persons range of needs, with a named single point of contact for individuals and their carers.

Prioritise and sequence interventions such as: structured medication review management and support, multifactorial falls risk assessment and action planning, cognitive assessment, treatment, care and support.

Holistic integrated proactive care delivered through multidisciplinary working means all aspects of someone’s health and wellbeing can be addressed in a managed way.

A named coordinator who provides a clear point of contact for advice is an important element of proactive care. Effective care co-ordination will help individuals navigate care across the health and care system and support them when receiving support from a range of services. Care co-ordination will also ensure service provision is coordinated, using a shared health and care record, and working to one personalised care and support plan. A care coordinator may be a member of the multi-professional team or an Additional Roles Reimbursement Scheme funded care coordinator.

Discussing clinical uncertainty within multidisciplinary team helps team members to understand the unpredictable nature of decline in frailty, engage in shared decision-making, and provide better support by weighing the risks and benefits of different clinical options.

Tools and Resources:

5.Continuity of Care

“I have a named person/ professional who supports the coordination of my care and is my main point of contact. They take the time to understand what is important to me, including my culture and identity.”“They attend MDT meetings where my care is discussed and make sure that I am included in all decisions about my care. We discuss what recommendations have been made by the MDT and they make sure I have all the information I need to be able to decide what support I want.”

“We have regular reviews to make sure that my care is working for me, and I know I can raise any concerns I have. I can ask them any questions and can contact them whenever my circumstances changed, and I need my personalised care and support plan to be updated.”

“Based on my needs and what matters to me, the MDT will suggest referrals to other services as needed. This could include health services, social care or services provided by the voluntary sector.”

“I am provided with accessible information about available services, in a way that meets my needs. I can decide which services I access and if something isn’t working for me, I can speak to my named coordinator about making change changes to my care.”

Provide a clear plan for continuity of care, including an agreed schedule of follow ups and future review.

Continuity of care enables personalised care, improves care quality, boosts a person’s confidence in medical decision-making, and fosters greater job satisfaction for health and care professionals.

A strengths-based approach increases knowledge and awareness which helps individuals to make informed decisions.

  • Continuity of care helps avoids duplication of effort and makes better use of available resources. It is more cost effective and improves overall efficiency of care delivery.

Tools and Resources: