Proactive Primary Care for escalating frailty

Proactive care identifies and targets people at risk of poor health and social outcomes and provides coordinated and tailored support to help them stay well. Individuals at risk of poor outcomes are identified using screening tools combined with professional judgement. Those with significant or escalating risk are offered a comprehensive multi-disciplinary assessment and appropriate interventions co-ordinated by a local multidisciplinary team of healthcare, social care and community or voluntary service partners working together.

The older person and their carer or family will be involved in developing a personalised care plan based on their goals and preferences. Emerging evidence shows that the approach can improve care continuity and coordination and reduce emergency attendances, particularly if it is supported by rapid access to alternatives to acute care closer to home.