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Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Proactive Care

Because the care system does not address their needs, many older patients and their caregivers have a poor quality of life

(Beswick AD, 2008).


The problem with many local systems and services for the frail/elderly population is that such services have : 

  • Grown historically and in an unplanned way

  • Become poorly aligned with the needs of local patients

  • High levels of variation from area to area

  • Gaps in care pathways due to locally absent resources

  • Duplicate process, such as assessments,

  • Too many ‘hand-overs’ of care, which generate confusion amongst patients and clinicians

  • Inappropriate utilisation of Out Of Hour services, subject to poor representation and poor integration of OOH sevices with primary/secondary/tertiary care resources.

  • Too many patients inappropriately admitted to acute hospital beds

  • Staff who become disillusioned when they are not empowered to provide the highest quality care

    Many current systems and services are also too reactive and hospital-centric. This is not affordable, doesn’t offer good quality care for patients and is not sustainable as the number of frail and elderly in the population increased. (Armstrong K, 2012).




The Local Authority Challenge


The challenge for the local authority is to develop a local integrated proactive care service model to be used by all Clinical Commissioning Groups, their local authority partners and frail/elderly populations.provider organisations to deliver seamless and integrated services for the frail/elderly population.


Such a model would have the following characteristics :

  • It will proactively identify and care for frail/elderly patients at every stage of the pathway

  • It will have one integrated health and social care multidisciplinary team (MDT) at the heart of the service

  • The MDT team will be community service. The MDT replaces the other local fragmented, independently operating, and often duplicated services.


The model might look like this :

Proactively caring for the elderly and those with complex need in Sussex. (NHS, 2012)

This proactive care model embodies a patient centred approach. The approach is preventative and aims to work with the clients physical health, mental health and social care needs .


The design of care is holistic and support is provided via a dedicated multidisciplinary team (MDT) wrapped around the client needs.


Clients are supported by a multitude of professionals led by a General Practitioner and supported by a Community matron, Physiotherapist, Occupational therapist, Social Worker, Community Psychiatrist Nurse, Prevention and assessment team, Geriatrician support, Team lead and administrative support. Further support from Public Health and the Voluntary sector.


The multidisciplinary team might look like this :

Proactively caring for the elderly and those with complex need in Sussex. (NHS, 2012)

The GP challenge


The challenge for the  GP located in a community where the local authority has not yet met the challenge of providing a local integrated proactive care service for its frail/elderly population, is to provide proactive care within the time and resource constraints of  his/her own practice.
Best practice includes the appointment of a practice lead, supported by named and dedicated nursing and administrative staff..


NHS support to this end is available and endorsed by the Royal College of General Practitioners

(NHS-1, 2014)


The new 2014/15 enhanced service (‘Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people’) now referred to as the ‘proactive care programme’,– together with new opportunities for CCGs to shift funding1 into primary care services and community health services – is designed to bring about a step change in the quality of care for frail older people and other patients with complex needs.

(NHS-2, 2014)

Proactive Care Team, CGA based Proactive Primary Care of the Elderly

This is one of four Read More sectors of the

Proactive Care chapter of this toolkit

Back To : Proactive Care

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