Staff discussion in office

Proactive Care

Proactive Care is proactive health and care intervention at individual and population level. It is targeted at people living with frailty, multi-morbidity and or complex needs to help them stay independent and healthy for as long as possible at home or the place they call home focusing on what is important to the individual.

Proactive Care (formerly known as 'Anticipatory Care') is managed by local Primary Care Networks (PCNs), so your Care Co-ordinator and the health and care professionals supporting you on your journey will be local to you and have extensive knowledge on relevant services and support options close to where you reside.

Your local GP is part of the wider Proactive Care team and will play a role in your care throughout. Because our teams are locally based and work together closely, your care is fully coordinated and where possible, can be carried out at home. Your GP practice team remain the primary point of contact for any new or urgent health concerns. 

The proactive care coordinator will be aiming to put you in touch with other community resources to support your needs and help you stay healthy, they can also discus any new problems identified with your local multi-disciplinary team.

Please note this service is expected to officially launch 1st April 2023.

Want to understand how Proactive Care could work for you? Check out our fictional examples of patient case studies.

Patient case studies

Why Proactive Care?

The aim of Proactive Care is to help people with long term conditions to live well and independently by supporting them to manage their health and care proactively.

Typically, this will involve an initial assessment with one of our locally based Care Co-ordinators with the potential for further assessments with other team members dependent on the individuals needs. Together we will make a plan about the things that are important to the individual, their health and their wellbeing. 

The Proactive Care Service is part of the NHS Long Term Plan, working alongside Primary Care, Social Services and Volunteer Organisations to support individuals to help manage their own health and wellbeing. Anticipatory care is about understanding what matters to you and working together to make a plan that fits any needs you may have.

What should I expect?

Proactive care starts with a conversation between you and your Care Co-ordinator. The discussion will include how you’re doing and feeling as well as what is important to you and matters most, to enable you to decide if you want to accept the Proactive Care offer. The Care Co-ordinator may then meet with your registered GP and a number of other health professionals known as a multi-disciplinary team.

What is a multi-disciplinary team?

A multi-disciplinary team (sometimes known as an MDT) is a group of health and care professionals that work together to assess and suggest treatment plans for individual patients and service users.

By bringing together professionals with lots of different skills, it enables them to take an overall view of your health and wellbeing and discuss how you might be best supported with your needs and plan the types of treatments and care that would be right for you.

This could include many aspects of an individual’s life such as their physical and mental health, social situation and circumstances, therefore providing much more thorough care and ongoing support.

Typical steps in your Proactive Care journey

The below offers a typical journey through an individual’s Proactive Care journey but don’t forget, each person is different, and your assessment and subsequent care plans are uniquely tailored to you and your needs and wishes:

  1. Identification: I have been identified as someone who may benefit from Proactive Care and have been invited to have an assessment of my needs.
  2. Holistic assessment: I will 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 on my life.
  3. Personalised care and support planning: My Care Co-ordinator and I discuss what matters to me in my life and what steps I could take to make my life better. Together we develop a plan about the things that are important to me, my needs and my aspirations.
  4. Multidisciplinary Assessment: A team of professionals may meet to discuss my needs and make recommendations about what might help me to achieve my aspirations. My views will be a priority at this meeting.
  5. Co-ordinated care: I have a named professional who supports the co-ordination 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.
  6. Interventions and support: Based on my needs and what matters to me, the MDT may suggest referrals to other services as needed.

What is a Care Co-ordinator and how can they support you?

A Care Co-ordinator supports patients in the community. They work with you to create tailored care plan to suit your needs and provide access to support services within Surrey Downs that are most relevant to you.

Your Care Co-ordinator will be with you at every step of the way during your Proactive Care Assessment and will be your main point of contact to ask any questions, answer queries or explain each step of the process.

I’ve been identified for Proactive Care but I’m not sure what to do

Your dedicated Care Co-ordinator will have made contact with you to let you know that you may benefit from an assessment to better support your needs. Your Care Co-ordinator would be happy to talk you through the process to see if this offer is something you would like to take up – it’s your choice – so please do contact them directly on the number provided either on the letter or leaflet given to you at the time.

We’d recommend you take up the offer of the initial assessment with your Care Co-ordinator, to understand how this service may benefit you and your long-term health – and remember, every care plan is tailored around you and your needs and wishes so you won’t need to attend anything or take up an offer that doesn’t suit you.

Example case studies

These case studies are fictional but are designed to provide examples of how Proactive Care may benefit individuals.

Patient case study: Jenny

Jenny is 65 years old and lives on her own. Jenny has been struggling recently and has reported difficulty breathing to the GP a number of times, has noticed that walking has become a bit more difficult and with the weather getting colder, is generally feeling a little more unwell each day. She has seen different GPs at each visit, who have referred Jenny for different scans and blood tests, but she is finding it hard to get a complete answer. 

Jenny was identified as potentially living with frailty via her GP on one of her visits. The GP referred Jenny to the local Anticipatory Care Co-ordinator who telephoned Jenny to ask whether she would be happy to have an assessment on her current needs.

Once Jenny had agreed, a full assessment was completed of Jenny’s health, social and self-care needs, and a personalised care plan was put into place, including a review by the Frailty Multidisciplinary Team.

Jenny received a medication review and referral to a local walking group where she can join local walks to keep her active.

Jenny was able to talk to the Care Co-ordinator throughout to discuss all of her recent tests, ask questions and work together to help manage her mobility both inside and outside of her home to keep her as active as possible.

Patient case study: Vijay

Vijay is 75 years of age and has visited his local A&E department four times in the past six months feeling unwell. Vijay was discharged each time within a few hours as the team could not find anything significant to treat, but Vijay feels like he is really struggling with his health. He tends to become unwell at night and during weekends and feels like A&E is his only option for help.

Vijay’s Social Worker refers him to the Proactive Care Co-ordinator who works with Vijay to understand his symptoms, listen to his concerns and signpost Vijay to a GP. A team of specialists, known as a Multi-Disciplinary Team (MDT), undertake a full assessment of Vijay’s symptoms and his needs to understand the root cause of why he might be struggling, and puts into place a personalised care plan to help Vijay manage his symptoms and know who to call at an earlier stage before he becomes unwell.

During a home visit, a member of the team notices that the house felt cold and there was black mould in the living room and refers Vijay to the housing department within his local council to rectify the mould which may be worsening Vijay’s symptoms.

Throughout his assessment and subsequent care plan, The Care Co-ordinator remains as a key point of contact for Vijay to ensure his care is fully joined up and Vijay feels supported throughout.

Patient case study: Gemma

Gemma is 55 years old and went to the GP last year for a minor problem. At the time of the appointment, the GP had concerns that Gemma may be at high risk for diabetes and asked Gemma to follow up with an appointment to discuss this further.

Gemma found it difficult to find time to make an appointment between her full-time job, looking after her family, and caring for an elderly relative and has not been back to the GP since her first appointment.

Gemma lives in an area that is flagged as having higher levels of diabetes and was identified by Graphnet, an online database that helps medical professionals identify individuals who may benefit from a Proactive Care assessment. The Care Co-ordinator got in touch directly with Gemma to explain why she had been identified and asked whether she could support Gemma through an assessment.

Gemma was a little reluctant at first, she simply doesn’t have much time for herself currently and doesn’t want to cause a fuss but agreed explaining that she has noticed feeling extremely tired recently which is starting to impact on her ability to do her busy job where she is on her feet all day long.

To work around Gemma’s schedule, the Care Co-ordinator arranged for the assessment to take place at her home. The Care Co-ordinator supported Gemma to arrange a GP appointment for a full health check. The GP subsequently refers her for some further health screening tests, arranges follow up reviews, and discusses how to manage pre-diabetes.

The Care Co-ordinator is in touch with Gemma throughout to ensure Gemma is kept in the loop and has the opportunity to ask any questions and discuss her personalised care plan to ensure it works for her. After a discussion about her diet, Gemma admits she struggles to sometimes afford fresh fruit and vegetables for the whole family and is referred to her local food bank who help provide nutritious meals when needed.

Gemma is also referred to her local health centre who offer free group fitness classes to help Gemma relax in her limited free time, meet new people and become a bit more active with something she enjoys doing.