Proactive care to provide care and support for people with moderate or severe frailty

NHS England have issued guidance on developing a more consistent and integrated approach to proactive care across the country for people living at home with frailty.

It aims to utilise existing resources, evidence and best practice to improve support for those with moderate or severe frailty. In particular, it also seeks to improve health outcomes and patient experiences in three ways:

• Delaying health deterioration where possible
• Maintaining independent living
• Reducing avoidable exacerbations of ill health, thereby reducing the use of unplanned care

And, drawing on the evidence and best practices from the NHS and internationally, it identifies five core components of the proactive care approach:

1. Identifying the target cohort for whom there is the greatest potential impact on health and system outcomes
2. Carrying out holistic assessments, such as a Comprehensive Geriatric Assessment
3. Developing a personalised care and support plan
4. Delivering co-ordinated multi-professional interventions to address the person’s range of needs
5. Providing a clear plan for continuity of care, including an agreed schedule of follow-ups.