Examples of proactive care services

How does the proactive care pathway work?  
The Keeping Well approach in Caddington Surgery General Practice is a model of shaping care around the individual who is living with moderate or severe frailty and dedicating extra time to exploring what matters most to patients. Frailty is treated like a long-term condition, and patients are put on the register with regular recall. It’s a team approach, involving a nurse practitioner, GPs, reception staff, pharmacists, a social prescriber and care co-ordinator.  

How are people identified? 

1. “Soft intelligence red flags” are picked up by wider team, including reception staff, pharmacy staff, and good neighbour scheme staff and volunteers.  
2. Information from letters to identify those who may have frailty, such as A&E attendance with falls, and requests for equipment at home.  
3. Quarterly Electronic Frailty Index searches on practice records.  

How are people supported?  

• Ringfenced time for longer frailty assessment appointments 
• Recall system for follow up, like in long term conditions 
• Care co-ordination supports holistic care for patients.  

Keeping well process   

• Care Co-ordinator completes initial “fact find” conversation, exploring patients main concerns and goals, recent functional, social and medical issues, and current social support. The Care Co-ordinator arranges a frailty assessment, with attendance of carer, and arranged transport from Good Neighbour Scheme if needed.  If resource is available, they will also arrange a clinical pharmacist to review the patient’s medications.  
• Full Keeping Well Assessment completed by Nurse Practitioner or GP in surgery or visiting the patient at home. Spread across two or more appointments, person centred holistic assessments use the “5Ms of Geriatrics” to tailor support to patients and uses the Rockwood Clinical Frailty Scale to confirm diagnosis. Patients are provided with an electronic or paper shared care plan, with actions for the patients and clinicians. Patients are offered advanced care planning and added to the Keeping Well register for recall.  
• Three month follow up  is arranged to review goals, issues, mediations, actions needed, and frailty score. Ongoing review may be three to six months by the most suitable member of the team. Yearly frailty assessments are needed to assess frailty score and care needs.

 How was the service set up?  

Caddington Surgery General Practice has 5,400 patients, and the highest proportion of over 65s in Bedfordshire (25%). Since 2010, Practice Matrons have been delivering proactive care to housebound individuals with frailty and noticed a reduction in crisis cases. However, funding for this scheme was removed in 2019. Therefore, a team-based approach was developed which ringfenced frailty appointment time for GPs, Advanced Nurse Practitioners, Care Co-ordinators, and social prescribers. In 2020, the “Keeping Well” approach was launched, including an Advanced Nurse Practitioner, and longer frailty assessment appointments for each GP to use for patients in surgery or home visits. Care Co-ordinator input has been invaluable, alongside a local Good Neighbour scheme which provides free transport for patients.

Impact 

• Patient’s medications are rationalised and explained, medical management optimised, functional and social issues addressed and helped where possible, which usually leads to reduced crises.  
• Patient and carers report reduced stress as they understand their care more and feel better supported.  
• GP and nurse feedback suggest work is less stressful.  

Patient example  

Bill, a 73-year-old with type two diabetes who lived alone, moved to sheltered accommodation because of concerns about vulnerability, forgetfulness and poor self-care.  What mattered most for Bill was his constant swollen legs and his uncertainty about his medication. He also had mild memory impairment, poor mobility, anaemia, and liver impairment. Interventions included a medication review, ongoing diabetes education, referral to hospital which addressed a liver condition and anaemia. He was provided with ongoing follow up, compression hosiery, and social support. As a result, his legs are no longer swollen, and he has regained independence. He was initially referred to memory services, but his memory improved after adequate insulin and correct medication. He understands diabetes better and co-operates with the community diabetic team. There has been no readmission, no crisis, and he has regained his independence.  

Outcomes  

• Process measures demonstrate proactive ongoing case management of 120-130 of patients in the practice living with frailty, with medications rationalised, function and social care addressed, and care plans shared (with treatment escalation plans where appropriate). 
• This complex group are known to be high risk for unplanned admissions and crisis use of health and social services, polypharmacy with associated carbon impact, and carer stress. Anecdotal evidence from individual cases and team experience is of fewer crisis events and calmer more planned care, with patients understanding their care better, medications rationalised with improved compliance, and support with earlier social care assessments for help to remain independent.   
• There has been no formal evaluation to the Keeping Well work due to lack of resource.  
• Experience of the clinical team is that it is a benefit to staff wellbeing to have this system for patients with frailty.  

Funding 
The practice currently chooses to fund the ringfenced clinician time for a nurse practitioner and GP because of the perceived benefits. It is not contractually required or financially incentivised at present in primary care. Funding for a care co-ordinator, social prescribing and clinical pharmacy input are from PCN The Additional Roles Reimbursement Scheme.  

Top tips 

• Prioritise ring-fenced clinician time for frailty assessment and follow up.  
• Care co-ordination is a game changer and helps shape care for patients. 
• Ensure there is simple documentation, so staff know how to find resources such as care plans.  
• Recall and follow up to ensure initial investment of time brings maximum benefit.

Overview 
The Wirral peninsula is geographically small, with a population of 330,000 spread across large towns and rural areas.  Its residents experience stark health inequalities and differences in life expectancy. Particularly on its more densely populated east side, practice and PCN populations are overlapping and interwoven. In Wirral, local and national data showed clearly that those with higher levels of frailty are already the greatest users of primary, community and secondary care.  They are also most likely to need unplanned care, which may be avoidable with better proactive care. Working across the PCN and community teams, the Wirral’s proactive care programme aimed to bring together teams who were already supporting those with higher levels of frailty and chronic disease, where personalised, proactive, holistic assessment and care planning could improve their quality of life and potentially reduce unplanned care demands.  This meant the community trust’s frailty nurses and matrons working as part of an integrated PCN team.

How does the proactive care pathway work?  

The team identifies people with clinically identified moderate and severe frailty.  However, this is not exclusive and people with mild frailty are also supported where there are additional complexities that will benefit from a CGA approach. People are identified via referral from practices and community teams. The pharmacy team receives discharge notifications from the hospital, and these are reviewed to identify those who should be seen by the team. Risk stratification, using data in the primary care record is also used to identify people who may benefit.  The pathway from referral or identification via risk stratification begins with a triage review using relevant information available from both the GP and community trust health records.  This gives a picture of past and current needs and service involvement. After a phone call with the patient to confirm details, including starting to understand what is currently of most importance to them, the initial visit will be from the lead clinician. The CGA and care plan is completed over a series of visits (current average 3-4), with non-registered clinical staff doing some of the follow ups if appropriate. The referral and triage process is managed by the team’s care co-ordinator.  As patients with ongoing complex care needs require continuity and holistic care, the whole team, including the community trust-employed staff, use the GP patient record for their clinical documentation.  As planned review is part of the Comprehensive Geriatric Assessment process, the service uses a shared patient tracker to support both immediate care coordination and future planned follow up.  

How was the pathway set up?      
The development of the combined Ageing Well, Living Better Team was a joint project between Moreton & Meols PCN and Wirral’s community trust.  It was the product of several months’ development and exploration of cohorts, activity, barriers and gaps to be overcome. It was finally enabled with a one-off six month funding agreement by the community trust for additional resource to enable proof of concept without taking resources from, or disrupting the community trust teams working beyond Moreton & Meols. The combined core team is made up of people working for the community trust, PCN, and the hospital trust. The team consists of six members of staff, including registered and non-registered clinicians and administrative staff, who look after 30,000 patients.   

Several key building blocks that have supported the way the team works were:  

• The information sharing agreements and access to PCN practice EMIS systems that was granted to the community trust staff  
• The design and build of the patient tracker (an Excel-based tool on a shared Teams channel, accessible to PCN and community trust staff) and the customisation of assessment and care plan templates in EMIS  
• The development of EMIS searches to support drawing together information for triage, and for risk stratification   
• Co-location of the team in a PCN building

Evaluation
The service holds regular meetings with the team with an aim to monitor the service, assess success, implement improvements, and gather feedback from staff.  

Impact
Removing barriers to good care
The service uses a shared primary care system which allows all staff in primary care practices to see proactive care interventions, saving community trust time which was previously spent writing letters and avoids formal referrals. The close co-ordination across the team also avoids duplication between PCN and community trust staff and allows for better communication.

An improved offer
The extended team at PCN level brings together a range of advanced skills and experience, resulting in more support without needing to request action from a GP. Initially, there was concern that a more proactive approach would need more GP input. However, the opposite has been the case and using a sample of 100 patients, GP and nurse appointments have reduced by 10% following the frailty team’s input. The team supports individuals who are “just about managing” but do not have support available, which should result in fewer care crises. The service expects to show, after 12 – 24 months, a reduction in A&E and unplanned admissions.

Better staff and patient experience
This more proactive, person-centred and closely coordinated way of working has increased job satisfaction.  One team member said, “I love my job. This is what I came into nursing for.”

Similarly, patient feedback has been positive.  A family member of one patient said, “Brilliant.  I felt for the first time in a long time that I was getting support in managing her at home and keeping her at home for as long as possible.”

Next steps
The success of the model in Moreton and Meols has resulted in the community trust aligning all matrons, frailty nurses, and related staff to PCN footprints. This will enable the model to be co-developed with each PCN in Wirral.  At this stage, this does not involve additional funding beyond what is already allocated for the existing community trust teams and the ARRS roles in the PCNs.  The integrated team uses this resource better than parallel teams.

Top tips

1. Explicitly building a ‘team of teams’ across PCN and community services has been essential for making the most of collective resources.  Doing this with the team, recognising that it takes time and won’t be perfect straight away, has been critically important.
2. A CGA-driven process has been invaluable in supporting holistic, person-centred assessment and care planning.
3. Co-location of PCN and community staff.
4. A single referral pathway and one point of care co-ordination removes duplication, and the care coordination extends to building relationships and knowledge across and beyond the PCN to health, social care, community and voluntary sector services.
5. Pooling PCN and community resources, which included advanced clinical practitioners and prescribers, means that more work can be kept within the team, who are less likely to need GP input.
6. Sharing a single clinical system with the same assessment and care plan templates makes information available to the wider practice teams.  This promotes assessable, continuous information across GP and ensures QOF related information is captured in one place. 
7. Retaining access to the community trust system has widened the information available to support good triage, whilst also making onward ‘referrals’ to community services quicker and simpler.  Bringing together the PCN and community team members’ knowledge of their respective organisations has been very beneficial. 
8. A shared patient tracker supports planned review and helps align planned CGA review to chronic disease reviews.
9. Using simple risk stratification, run monthly, to identify a number of people expected equal to any capacity left after referral demand has been met means full utilisation of the team’s capacity.
10. Monthly reporting to individual practices about their patients who are being actively supported by the team supports coordination between GP and PCN teams, whilst practice-level activity reports demonstrate the work of the team and highlight the benefit of referrals from practices.

How does the proactive care pathway work?  

The Proactive Ageing Well Service (PAWS) strives to see patients with moderate frailty in the community for a proactive, preventative Comprehensive Geriatric Assessment with the ambition to keep them well at home. They work with other medical services who screen patients for frailty using the Rockwood Clinical Frailty Score (CFS) and provide service with the patients’ details so that they can arrange a holistic assessment within their home.  The services that screen patients for frailty include GP practices, district nurses, community therapy teams, older age mental health services, community heart failure teams and the acute hospital Emergency Department teams at the Whittington. All patients with a CFS of 6 will be proactively assessed by the team in a systematic way.  They do not need to have any acute or new problems: the only criteria are that they are CFS 6 and have not had a CGA in the last year.   

How are people supported?  

Patients are seen by a multidisciplinary frailty team within their home for a holistic, patient-centred comprehensive geriatric assessment, where issues are identified, a care plan is developed, and referrals are made to appropriate services.  The service recognises that a lot of people are living with moderate frailty and trying to support themselves, but this is not formally identified, diagnosed and managed.  As a result, these patients are only diagnosed once they have severe frailty and starting to use acute and community services.  The service aims to see these patients proactively with the objective of intervening early and hopefully slowing or halting the progression of frailty and the consequences of this.   

How was the service set up?  

In 2014, Whittington developed a community frailty service called the Integrated Community Ageing Team (ICAT), who undertake comprehensive geriatric assessments for patients in their home and support the local care homes.  The ICAT team primarily see patients with severe frailty who are referred with a range of complex frailty issues.    

In 2017, a group of GPs in Islington in North London were given some money to develop services that they felt that their patients would benefit from.  They felt that proactive frailty assessments would be helpful and approached Whittington Health NHS Trust to support them with this, so the PAWS team were set up.  The success of this project resulted in the service being rolled out across the borough.  They have recruited a multidisciplinary team, including a frailty nurse, physiotherapist, pharmacist, AgeUK navigator, and administrator, supported by a consultant geriatrician and a specialist GP in frailty.  They work together with the Islington GP federation, who have developed a service level agreement with all local GP practices to allow access to EMIS GP records and document our assessments on EMIS.    

What difference has been made?   

Patient:  

• Patients are often trying to manage in the community and have not presented to services yet.  This holistic assessment allows them to raise their concerns and provide early support from health services, social services and charitable organisations.  Without this service, the patients would not have had any assessment, or possibly disjointed care.  
• The patients are often identified with a range of frailty syndromes and will have evidence-based interventions to support them.  An example of this is if patients are having falls, they will have a multidisciplinary falls assessment, a pharmacy review and screening/treatment for osteoporosis.   
• This service provides joined-up care for patients with clear communication with general practice and community services.  This ensures that the patient’s concerns and treatment are available for other services, and this reduces duplication.  

Staff:   

• The community and primary care teams that are seeing patients with moderate frailty now have a pathway to enable these patients to be seen.  Prior to this, they would often recognise frailty but were unclear of the best way to support the patients proactively.  
• For the PAWS team, it is incredibly rewarding to assess patients and provide a holistic assessment within their home.  They are frequently seeing cases where patients have been struggling to manage on their own and are extremely grateful for the interventions.  
• The team is a collaboration between an experienced clinical MDT, Age UK Islington and the local GP Federation.  This level of integration ensures that all the patient’s needs are considered within one team, and they are not working in silos.    

For services/system   

• This service is an example of implementing proactive care as outlined in the NHS England Proactive Care guidance from December 2023. The North Contral London ICS were ahead of the curve when they commissioned this service in 2017. It has been used by NHS England as an exemplar of proactive care.  
• Although the primary aim of the service improving patient care and wellbeing, the service recognises the importance of proactive, preventative work on the wider NHS and social care systems.  By identifying frailty early, the objective is to reduce the patient’s morbidity and mortality and in turn reduce need for hospital admissions and social care.  Examples of this include reducing polypharmacy, assessing for falls and osteoporosis, diagnosing dementia at an earlier stage and ensuring a multidisciplinary intervention, and recognising social isolation and increasing community support for patients to promote wellbeing and reduce low mood.   

Outcome measures  

• Since 2021, the service has assessed over 1200 patients with moderate frailty.    
• They identified a wide range of issues and referred over 500 patients to other services.  Examples include audiology, community dentists, bladder and bowel services, charitable organisations and the memory team.   
• The service has started evaluating the accuracy of the referring teams Clinical Frailty Scoring.  
• One of the challenges the service experienced was finding a robust way to evaluate if proactive interventions have reduced acute hospital presentations and need for social care.  

Patient Story 

Mr X is a 77-year-old man that was identified by the emergency department in a local hospital as likely to benefit from a CGA. He was given a Rockwood frailty score of six and attended the ED department on a few occasions in recent months with a urinary infection and blocked catheter. His medical history included heart failure, impaired vision and benign prostate hypertrophy with an indwelling catheter which was inserted in the last year. The patient’s goal was to remove the catheter, improve mobility, and help with activities of daily living to improve function.  After his initial assessment, he was discussed in the weekly MDT meeting with the consultant. A care plan was developed to include a physiotherapist assessment to improve confidence, urology referral, medication review, social service referral, and advanced care planning. Mr X remained on the service caseload until the care plan was completed. He had an allocated key worker within the team to oversee his care and liaised him and with all appropriate clinical and social care teams.  On the completion of his care a timely discharge letter was completed. A copy was sent to Mr X and his GP. Outstanding actions for Mr X and GP included advice around future referral to talking therapies should Mr X want this in the near future.    

Funding  
The service has received recurrent funding for this project and staff are now permanent.  This is crucial as non-recurrent funding makes it significantly harder to recruit and retain high quality staff.   

Top tips  

• Identifying the right patients: initially, the service used the Electronic Frailty Index (eFI) from GPs to identify patients with moderate frailty for assessment.  However, eFI often over-estimated the level of frailty. Therefore, the service sought the support of NHS community colleagues to ask them to undertake a Rockwood Clinical Frailty Score on suitable patients. Crucially, with a data sharing agreement, these teams do not need to consent a patient for a referral or complete a referral form. They only have to provide us with their NHS number.    
• Data access: having access to the patient’s primary care health records and being able to write onto the GP’s notes has been crucial to the service.  The data sharing agreement with GP practices means the service doesn’t have to get explicit consent for each patient, so this reduces the administrative burden.   
• Collaborative approach to patient-centred care: the principle of developing a service that combines primary care services, community services and charitable sector has been invaluable as it ensures shared learning and clear communication that allows the service to think of the patient a whole. 
• Frailty education: When seeking support and engagement from other services, the service found that it was helpful to start with some frailty educational events for the teams so that they were more confident with identifying frailty and the potential interventions that will support patients.   

Overview 
The Keeping Well Dunstable Hub started as bi-weekly clinics and now operates weekly, after extensive collaboration between Bedfordshire NHS Trust, Chiltern Hill PCN, and the community service from the East London NHS Trust.  The Frailty Service from Bedfordshire NHS Trust is represented by a dedicated team comprising of Frailty Advanced Care Practitioners and a Consultant Geriatrician, all of whom are specifically allocated to the clinic. The Chiltern Hills Primary Care Network is made up of six GP Practices.  

How does the proactive care pathway work? 
Chiltern Hills Care Co-ordinators identify a cohort of people with frailty who are frequent users of primary care, are housebound or present with frailty syndromes. These patients are referred to the clinic via a dedicated email system. Once a referral is accepted, patients are contacted by telephone and invited to participate in the holistic assessment and support process. They are given the option to attend the Dunstable Hub in person or to receive a home visit, depending on their needs.  

Patients are seen by a Frailty Consultant and Advance Care Practitioner who will undertake a Comprehensive Geriatric Assessment including psychological, cognitive assessment and functional review as well as physical examination. An individual care plan including medical problems and medications is formulated and shared with patient and GP, uploaded on SystemOne and available in the clinical portal for acute hospital staff. An individualised care plan also includes information about the frailty virtual ward that patients can contact in crisis situations and link to the advanced care plan that patients and family can fill in and print it out.  All patients attending the Hub are also offered a conversation with a care co-ordinator and a pharmacist. Additionally, if they have not had a basic blood test in the last six months, they are provided with one to ensure a comprehensive assessment of their health status. Interventions include referrals for complementary services such as podiatry, ophthalmology, hearing assessment, and identify those whom reduction in polypharmacy, advance care planning and quality of life is the main priority. Patients also have a faster access to diagnostic and specialty referrals via frailty same day emergency unit if required. Other patients have their multiple appointments reviewed and cancelled if it seems inappropriate.  

In addition, patients are identified for in-group exercise programs, which are run by Active Lifestyle Coordinators from the Bedfordshire Council with support from the frailty team. Alongside these exercise sessions, educational sessions are also set up to help service users better understand frailty syndromes, empowering them with knowledge to manage their conditions more effectively.   

Patients and/or their carers receive a follow-up phone call from their care co-ordinators one week after the clinic. This call is intended to address any further questions they may have and to collect feedback about their experience. Data is also gathered on the number of patients seen, the care plans created, and the interventions implemented. This information is used to continuously improve and further develop the service.  

Patient example 
A 89-year-old patient, living with his wife and using a Zimmer frame for mobility, was referred to the clinic by a Care Co-ordinator due to recent recurrent falls. The patient had a Clinical Frailty Scale (CFS) score of six. During the clinic review, the patient reported a 12-month history of reduced mobility, a worsening shuffling gait, as well as sleeping and swallowing problems. Following the assessment, the patient was diagnosed with Parkinson's disease and significant postural hypotension. In response to these findings, the patient’s antihypertensive medication was discontinued, and a referral was made to the Parkinson’s disease (PD) service. Additionally, a bone health assessment was completed, and referrals were made to speech and language therapy (SALT) and social services. The patient was also provided with advice on Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Power of Attorney (POA) and given access to the frailty virtual ward for ongoing support if in crisis. Feedback from the Patient and Family: "We couldn’t believe that we were listened to and sat down with for longer than 10 minutes. We had been asking for help for a long time without success. After the clinic, we finally know what is wrong and how to get help. We were surprised that this service exists just around the corner."  

Future of service 
The service is focused on expansion, which includes continuing to recruit and train frailty advanced care practitioners and strengthening relationships with GP practices. Additionally, further work is in progress to expand upon the Luton and Central Bedfordshire Keeping Well Clinic, ensuring provision of comprehensive and proactive care to even more patients in the future. The service is developing a ‘flag’ on SystemOne and clinical portal to alert the health professionals that the patient is known to the frailty service for further support if required.

How does the proactive care pathway work?  

The North West Surrey Locality Hubs service is a community-based integrated physical health, mental health and care service for older people with frailty.  There are three hubs based in community hospitals and there is free community transport to the hubs to bring people to see team members.  The team also visit people at home who are housebound.  The hubs are staffed by matrons, GPs, hub coordinators who support people with their social needs, pharmacists, mental health practitioners and social workers.  There are also consultant clinics in the hubs and the hub team has close links with the community therapy services.  There is real time record sharing between the hubs and GP practices.   

The service is designed so each team member carries out a specific role which reduces duplication and ensures the patient gets the best advice.  Templates were developed to ensure that assessments are consistent.  Professionals are encouraged to manage issues within their specialist area and hand over patients with problems beyond that to the appropriate colleague.  All team members work in the same base, use the same clinical record system and share patient care which has promoted better understanding of the role and expertise of each professional group.    

The physical location of the Locality Hubs and free patient transport enables a ‘one stop’ approach so patients can be seen by several professionals and have investigations done on one visit rather than attending several appointments in different places.  Bringing patients to the hub saves clinicians time with less travel and fewer missed appointments, allowing more patients to be seen.    

Having in-house geriatric, cardiology and respiratory consultant clinics and access to specialist nurses and mental health professionals has helped generalist staff to increase their knowledge.  Team members can ask specialists for advice rather than making a referral, resulting in fewer referrals to specialists.  

How are people identified?   

The referral criteria for the service are any patient registered with a North West Surrey GP practice aged 65 or over with a Clinical Frailty Scale of 4-8.  The service accepts people younger than 65 who have severe frailty but it is aimed at older people.   Referrals are accepted from any health, social care or local borough professional.  Most referrals come from GPs with about a quarter coming from the local acute trust, mostly from the care of older people wards and A&E.  There is an agreed pathway for dementia diagnosis in the hubs and the acute trust dementia team can refer people with suspected dementia to the hubs for dementia diagnosis.  The hospital psychiatric liaison service can refer people to the hubs for a post delirium review.  

How are people supported?  

The service sees people with frailty and carries out a multi-disciplinary proactive assessment to identify their needs and provide advice and treatment, signpost to suitable services and put support in place before people go into crisis.  Once seen by the service they remain on the hub caseload for life and can contact the hub for advice at any time.  Each person is allocated a hub coordinator who is their main point of contact, and the hub coordinators keep in regular contact with people on the caseload with complex care needs.  Hub coordinators also provide support for carers of people on the caseload. 

How was the service set up?  

The Bedser Hub opened in Woking Community Hospital in January 2016.  The Locality hub model was developed as part of the North West Surrey CCG Frailty strategy and the Bedser hub was initially set up by a CCG project team working with the local community provider.  The service uses EMIS, and the CCG established information sharing agreements between the community services, acute trust, mental health trust and all the local practices to allow electronic record sharing.  The existing community matrons and virtual ward mental health practitioner formed the basis of the hub team.  The CCG provided funding for the hub coordinators, GPs and pharmacist who are employed by the community services provider.  The mental health practitioner is employed by the mental health trust.  Social care support is provided by the local adult social care team. 

The community services contract was put out to tender in 2016, and the Locality hub service was part of the new community contract.  In April 2017, CSH Surrey became the community provider and has been running the service since then.    

During the first two years, the Bedser Hub team developed and embedded the model, designed and implemented the hub reactive service, the hub dementia diagnosis pathway and new mental health pathways between the acute hospital and the hub for suspected dementia and post delirium review.    

Two new Locality hubs opened in 2018: The Ashford Hub opened in Ashford Hospital in February 2018 and the Thames Medical Hub opened in Walton community hospital in May 2018.  The new hubs used the model and pathways developed in the Bedser Hub which resulted in much faster and more efficient implementation of the service.  Referrers were already aware of the service so the initial referral rate was higher and local people had heard of the Bedser Hub so understood the Locality Hub service better.  

What difference has been made?   

• Patient and carer satisfaction is high with many positive comments.  
• Staff satisfaction and retention is high.  Recruitment is generally successful.  There is improved knowledge within team members and coordination between services has improved.    
• The Bedser Hub opened in Woking in 2016 whereas the other two hubs opened in 2018 allowing the impact of the Bedser Hub to be measured in 2017/2018 by comparing Woking locality data with data from the other two localities.  This demonstrated reduction in outpatient referrals to geriatric medicine and cardiology for people over 75, reduction in growth in emergency admissions for people over 75, increase in dementia diagnosis and increased access to psychological therapies in older people. 

Outcome measures and funding  

Data for outcome measures was collected during the pilot phase but the service has been running since 2016 and regular outcome data is no longer collected. The hub service is part of the community contract and provided by the local community provider. 

Lessons learnt 

• It takes time for a new team from different backgrounds to develop an understanding of each other’s roles and negotiate how they will work together.    
• Clinical input and leadership are needed at the design phase and start-up phase to ensure that the service works well clinically.  
• Project management support is useful in the start-up phase to manage the non-clinical elements such as recruitment, IT systems, room space and transport.  
• Establish clear processes at the beginning that support team members to work together and involve team members in developing the processes.  
• Non-clinical staff such as hub coordinators have a key role to play in supporting patients and carers and managing links with social care, local authority services and voluntary organisations.  
• Administrative support is valuable as it releases clinical time to see patients.  
• A co-located integrated team supports learning.  The GPs learnt a lot through working alongside consultants and increased the range of conditions they could manage.  Matrons increased their knowledge of medical conditions.  Hub coordinators learnt more about healthcare.  All team members learnt to manage mental health conditions better.    
• It can take time for referrers to understand the service and learn to identify suitable patients. 

Top tips 

• Don’t take on too much to begin with or team members will become overwhelmed 
• Nurture staff and manage concerns actively   
• Provide in-house training and development from the beginning  
• Spend time building external relationships   
• Promote the service to encourage referrals   
• Manage expectations. It can take months for the service to get up to speed and pushing for delivery at the beginning is counterproductive   

The Jean Bishop Integrated Care Centre for Integrated Care was established out of a need to move frailty care from a reactive, crisis-driven model to a preventative, proactive model aiming to deliver integrated, out-of-hospital care. The Centre provides care delivered by a multidisciplinary team which includes geriatricians, nurse practitioners, general practitioners with an extended role in frailty care, pharmacists, occupational therapists, physiotherapists, social workers, clinical support workers, carers’ support and volunteers. The service identifies individuals at risk of moderate or severe frailty using the electronic Frailty Index (eFI) and a member of the team visits contacts the individual in their own home or care home to pre-assess their needs and to identify any concerns that the patient may wish to discuss. For patients residing in their own home, a personalised appointment at the Jean Bishop Centre is then arranged taking 3-5 hours, providing all of the interventions that have been identified as necessary for that patient in a single appointment. The same model of care is delivered by a visiting care home MDT for residents residing in care homes. Interventions are based on the individual’s comprehensive geriatric assessment and individualised care needs.  

This model has been shown to benefit both patients and the system. Patients report sustained improvement in emotional and physical wellbeing while system benefits include reduction in unnecessary presentations to emergency departments, reduction in ambulance conveyances and saving GP clinic time. 

West Suffolk NHS Foundation Trusts (WSFT) community specialist frailty therapists, consisting of an Occupational Therapist (OT) and a Physiotherapist (PT), alongside Forest Heath Primary Care Network (FHPCN) agreed to pilot population health management risk stratification using a Cerner Oracle dashboard. The risk stratification dashboard segments the population by their risk of an emergency admission within the next 12 months. It is a predictive model, based on factors such as healthcare utilisation, comorbidities, and demographic profiles. The methods used for the frailty risk stratification PHM project included: 

• Data identified within HealtheAnalytics and verified by cross-referencing against GP record data for the specified cohort in FHPCN  
• Qualitative and quantitative data collection 
• Feedback interviews with professionals involved.

A core multidisciplinary team of a frailty specialist OT and PT, a GP, and a public health practitioner mapped the evidence of indicators and interventions identified for frailty against a risk pyramid. In total, 27 participants were identified for interventions following cross-referencing with the GP record, including assessing Electronic Frailty Index (eFI) score. Five people opted-out when telephoned and so 22 participants received the interventions available. Interventions were pre-selected or introduced later, following initial contacts and follow-ups. Pre-selected interventions included: Electronic Frailty Index (eFI), telephone calls, Nottingham Extended Activities of Daily Living (ADL) Scale, The Edmonton Frail Scale, advice, referral to another service, targeted personalised literature and education sent in the post and follow up phone calls. Interventions introduced later included health coaching conversations, patient activation measures, and home visits.  The cohort received multiple interventions and the following impacts were observed:  

• People found the information sent to them useful. 
• People were receptive to onward referrals to other health and care services, however, not all referral pathways worked straight away.  
• Home visits were helpful to people who received them.  
• Levels of patient activation improved for all those who completed a first and second Patient Activation Measure® (PAM).  
• Positive professional relationships between clinicians and organisations enabled project implementation.  
• Professionals found that having dedicated time to work in a preventative and proactive way was rewarding.  

The following learning points were established:  

• Provide support, learning and development opportunities to clinicians who want to progress population health management ideas and projects.  
• Provide clinicians with dedicated time to implement population health management ideas approaches, preventative interventions, and proactive case finding for identified needs and risk stratification.  
• Use the available evidence-base to inform the design of population health management ideas projects.  
• Establish a positive working relationship with a GP practice and clinical lead for the population health management ideas topic who can enable access to the tools, resources, and information already available in primary care.  
• Use an up-to-date eFI score as a benchmark for frailty and implement the established pathway to test the same again in another GP practice or scale delivery to larger cohorts in the existing practice.  
• Interventions need to be adaptable to support people in a meaningful way to them and address any unmet needs identified.  
• Use existing literature and tailor its distribution, including in other formats to support increased knowledge in condition specific information and local offers.  
• Improvements identified for referral pathways must be implemented for future projects to succeed.  
• Use PAM to inform tailored health and care interventions and demonstrate impact.

An outreach proactive care model was established across six GP practices in Sheffield, led by an Occupational Therapist working closely with a Care Co-ordinator, and social prescribers. Patients were identified through Systmone records frailty codes and telephone screening by a care co-ordinator. Once identified, patients were offered a holistic assessment focussed on what matters to them, identifying patient and carer goals. Interventions were patient-led, with a preventative and self-management focus. They included nutrition and hydration advice, fatigue and pain management, equipment provision, and medication management. After interventions were completed, patients were supported with ongoing signposting and annual reviews. 124 patients living with moderate to severe frailty were contacted for a review, and 51 patients were identified for occupational therapy input. Therapeutic outcomes were measured using the Goal Attainment scale and all patients receiving occupational therapy attained at least one therapeutic goal. Patient feedback: “it’s helped with my confidence; I’ve made contact with friends and use the trolley in the kitchen”.  

The implementation of the outreach model of practice demonstrates the high value of occupational therapists working collaboratively in preventative roles to improve the lived experience of older adults with frailty. This model evaluates as ‘fit of purpose’ and is continuing to be developed in the Primary Care Network.  It illustrates how occupational therapists can provide accessible, supportive interventions promoting occupational performance and wellbeing in this context. 

Weymouth and Portland Frailty Team launched in April 2015.  Well before the development of Primary Care Networks (PCN’s), this area had the vision and foresight to start working at scale across the locality to develop a service under leadership of Dr Laura Godfrey and strong support from GP Surgery leads. The team covers a footprint of 76,000 registered patients.   

The Frailty Team has evolved over many years from small roots with a part time GP and a part time Nurse practitioner, to expand to include Advanced Clinical Practitioners, Specialist Frailty Nurses, Paramedics, Occupational Therapists, Physiotherapists, Care Co-Ordinator and Health Care Assistants. There are close links with community services meaning they are already well placed for working as an Integrated Neighbourhood.   

The Team ethos is focused on Proactive Care and early identification, supporting patients with known Frailty to live well in their own homes and personalised care and support planning to underpin patient care.  They also believe structured medication review with a focus on deprescribing and reducing polypharmacy is vital.   

The service has been through several iterations of a Proactive Frailty Housebound Service which initially focused on moderate frailty, but subsequently for any housebound patient with any level of frailty with unmet needs or personalised care and support planning needs. The assessment follows the principles of a Comprehensive Geriatric assessment, although delivered by a single clinician. Having spent many years providing regular review, it became clear that ad hoc visits were not a good use of a limited resource. Therefore, the service moved to a dormant frailty caseload in 2023, which gave patients direct access to the frailty team. The aim is that the patient or carer can be supported early to prevent further decline or admission. Key to success has been a willingness to evolve and adapt, detailed SOPs to ensure consistency, and a strong focus on “What Matters Most” to the patient. All patients now receive a written discharge letter as well as a written Personalised Care and Support Plan using the Dorset Care Plan.   

Throughout the service development, it has become increasingly evident that patients were not being seen early enough. In January 2022, a funding opportunity arose, and it became possible to develop an ‘ageing well clinic.’  This has been developed to deliver a true Comprehensive Geriatric Assessment, held in a community setting and has input from Frailty Practitioner, therapist, care co-ordinator and social prescriber. There is also willingness to accept referrals from any source and not just from healthcare colleagues, but also from community and voluntary sector and self or family member referral. This clinic inspired the development of a quarterly ‘Health and Wellbeing Fair’ to get even earlier messages out to patients.    

 Finally, there is a focus on risk profiling through a variety of methods, such as monthly searches for patients newly coded with moderate frailty, utilizing the electronic frailty index searches monthly to look for rising eFI as a surrogate marker for increased frailty, and utilizing the DiiS (Dorset intelligence and insights service), particularly to look at patients at risk of falls. 

Future Plans  
The service has two areas of focus for the next year.  The first is to work more proactively with patients who are at risk of frailty or who already have frailty who have been admitted to hospital. The second is around falls prevention through structured exercise programs, particularly FaME (Falls Management Exercise) which has been shown to reduce fear of falling, improve physical function, improve balance confidence and quality of life.   

Top tips  
Vital to the successful development of this Proactive Frailty Team has been a forward thinking locality, shared admin via SystmOne, development of strong links with community teams, ARRS staff and the VCSE.   

All staff in the Frailty Team and care coordination team undertake frailty training as part of their induction, as well as training via the personalised care institute on personalised care and support planning and shared decision making.