Proactive Care

Proactive Care is a service provided by the NHS that offers personalised and coordinated multi-professional support and interventions for people living with complex needs.

The specific aims of proactive care are to improve health outcomes and patient experience by delaying the onset of health deterioration, maintaining independent living, and reducing avoidable exacerbations of ill health.

Patients enrolled in the Proactive Care program can expect a comprehensive and personalised approach to their healthcare. This begins with a holistic assessment of their health status and needs, considering not just physical health, but also mental and social factors.

Based on this assessment, a personalised care plan is developed. This plan outlines the interventions and support that will be provided to the patient, tailored to their individual needs. The care plan is not static but is regularly reviewed and adjusted as the patient’s needs change over time.

A care coordinator is assigned to each patient. They play a crucial role in ensuring the care plan is implemented effectively and coordinating with all the different professionals involved in the patient’s care. The care coordinator is the patient’s main point of contact and is there to support the patient throughout their journey.

The care and support provided can involve a range of interventions, from medical treatments to social support. The exact nature of the care provided will depend on the individual needs of the patient, but the aim is always to improve health outcomes, maintain independent living, and reduce avoidable exacerbations of ill health.

In addition to the healthcare professionals, patients can also expect support from a variety of other stakeholders, such as voluntary sector organisations, housing associations, and social services. These organisations can provide additional support and resources to help the patient manage their health and wellbeing.

Overall, patients can expect a coordinated and comprehensive approach to their care, with the aim of improving their health outcomes and quality of life. The Proactive Care service is there to support them every step of the way.

Health and Social Care Coordinator play a crucial role in the Proactive Care service, providing a vital link between the patient and the various healthcare professionals and services involved in their care. Their goal is to ensure that every patient receives the care and support they need, when they need it.

The care provided under the Proactive Care service is delivered by a diverse team of professionals who work together to ensure the best possible outcomes for the patient. This team is often referred to as a Multi-Disciplinary Team (MDT ) and can include a variety of healthcare professionals such as doctors, nurses, physiotherapists, occupational therapists, and Health and Social Care Coordinator.

Health and Social Care Coordinator play a crucial role in this team. They help to navigate and coordinate care across the health and care system, ensuring that patients make the right connections with the right teams at the right time.

In addition to the healthcare professionals, there are also a number of other stakeholders who may be involved in the patient’s care. This can include support from the voluntary sector, housing associations, social services, and more. The exact composition of this team can vary depending on the individual needs of the patient, but the aim is always to provide a comprehensive and coordinated approach to care.

It’s important to note that not all patients will require support from all these organisations, but they are available for those who do. The goal is to ensure that every patient receives the care and support they need, when they need it.

The Proactive Care service is designed to guide patients through a journey of care, tailored to their individual needs. This journey typically involves six key steps:

  1. Identification: The first step is identifying the patients who would benefit most from the Proactive Care service. This is usually people living with complex needs.
  2. Holistic Assessment: Once identified, a comprehensive assessment is carried out to understand the patient’s health status and needs. This assessment is holistic, considering not just physical health, but also mental and social factors.
  3. Care Planning: Based on the assessment, a personalised care plan is developed. This plan outlines the interventions and support that will be provided to the patient.
  4. Care Coordination: A Health and Social Care Coordinator is assigned to each patient. They are responsible for ensuring the care plan is implemented effectively and coordinating with all the different professionals involved in the patient’s care.
  5. Delivery of Care: The care and support outlined in the plan are then delivered. This could involve a range of interventions, from medical treatments to social support.
  6. Regular Review: The patient’s progress is regularly reviewed and the care plan is adjusted as needed. This ensures the care provided continues to meet the patient’s changing needs.