Anticipatory care: working with community services to provide enhanced care for complex high risk patients
As part of the five-year GP contract, primary care networks are required to develop an anticipatory care approach. This involves joining up primary care with community-based services to provide more proactive and intense care for patients who are at a high risk of developing poor health, including patients receiving palliative care. The aim is targeted support for severely frail older patients as well as people of all ages living with multiple commodities, and to build on the work of the vanguards.
This session will hear examples of anticipatory care in action. You’ll hear from a primary care home and network which has developed a single responsive team covering community nursing, mental health practitioners, a psychologist, Age UK, physiotherapist, and a housing co-ordinator to provide anticipatory care for high risk patients. This will be followed by two PCNs in Bedfordshire, Luton and Milton Keynes Integrated Care System (ICS) that are developing integrated working with community care services including proactive care planning for frail patients.