Proactive care in South West London provides an integrated, personalised and co-ordinated approach to health and care. Targeted at people aged 18 and over living with moderate to severe frailty and multiple long-term conditions proactive care will help them stay independent and healthy for as long as possible at home.
The service is led by local Primary Care Networks and is delivered by neighbourhood multidisciplinary teams of health and care professionals (MDTs) from a range of local health, care and voluntary sector organisations.
Proactive care focuses on providing health and care support based on what is important to the person. It gives people choice and control over the way their care is planned and delivered. Care is based on an individual’s strengths and needs and what matters to them.
A personal care plan is developed with the individual at the centre and it takes a “whole person” (holistic) view. This means considering a person’s physical and mental health, social and self-care needs and how all of these impact on a person’s life.
Interventions and support are tailored to the person’s needs and preferences and a named care coordinator is responsible for ensuring the continuity of a person’s care and will help them navigate the local health and care system.
Proactive care also helps to reduce the risk of long-term health conditions worsening which could result in a person needing unplanned emergency care and hospital stays.
Early results from Kingston and Richmond’s Proactive Anticipatory Care (PAC) service pilot shows that patients who have been part of their PAC service for four months or more have reduced their use of urgent or unplanned care by 48% (July 2023).
It will also help to improve health inequalities because care is focussed on people experiencing the worst health outcomes as a result of inequality.
Proactive care is a key priority in the NHS South West London Joint Forward Plan 2023 – 2028.
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