The Proactive Anticipatory Care (PAC) model focusses on a specific group of patients – those with multiple long-term conditions and frailty who are becoming reliant on emergency care as their health deteriorates.
PAC helps these patients stay healthier and more independent at home for longer and reduces the need for emergency health care. PAC also supports activity to address aspects of the wider determinants of health – the diverse range of social, economic and environmental factors that influence a person’s health and well-being and any inequalities they experience.
Dr Annette Pautz, Clinical Lead for PAC and local Kingston GP said: “We identify people in the community who would benefit from this model of care. We look at all elements of their health and wellbeing and work with them, their families or carers to create the right health and care plan for their individual needs.
“We’ve had really positive feedback from patients who have been pleased with such a personalised approach. They say they really enjoy being able to work so closely with one named person who supports them to achieve their care plan goals.”
Eva is 74 with a number of long-term conditions, including diabetes, and social care needs because of mobility issues. Eva frequently visits her GP but also goes to A&E in times of crisis and has had emergency hospital admissions.
She has been referred to PAC. She is assigned a Care Coordinator and a Care Lead. Eva meets her care coordinator regularly and he develops, with her and her family, a goal-based care plan, which is centred around Eva’s needs.
Eva’s care is discussed at a multidisciplinary team (MDT) meeting which includes her GP, Social Care and Community Nurses. Specialists can also attend the MDT when needed. The MDT makes recommendations for Eva’s care to help her achieve her personal care plan goals. These recommendations are discussed with Eva – who is in control of her care. Eva’s care coordinator also supports Eva’s wellbeing by encouraging her to get more involved in her local community and meet people – this helps her to feel less lonely.
Because of PAC, Eva’s experience of local health and care has improved, and as her needs are being managed better and she is less likely to need unplanned hospital care.
The PAC model was developed with health and care partners across Kingston and Richmond. Health, voluntary and social care organisations work together to provide patients with joined up care through multidisciplinary teams across Kingston and Richmond.
Working across two PCNs in Kingston and Richmond, a PAC pilot launched in May 2021, with GPs referring suitable patients into the pilot. Patient feedback has been crucial in the development of the service. Patients have told us they feel more confident to manage their own care and that they have confidence that the MDT team has their best interests at heart to work with them, their family members and/or carers to develop a personalised care plan. Early results for the pilot show a significant reduction in unplanned care attendances after patients have been involved in the project for more than four months.
The pilot is planned to roll out across remaining PCNs in Kingston and Richmond during 2023/24.