Translate

Proactive Care Team

Our Proactive Care Team provides extra support for patients with complex health and social care needs. Working alongside your GP, Nurses, Paramedics, Care Coordinators, Social Prescribers, and our Integrated Neighbourhood Team, we ensure you receive the right care, at the right time, from the right professionals.

We work closely with hospital discharge teams, NHS 111, ambulance services, social care teams, secondary care services, and community teams (including District Nurses and Community Therapy Services) to help coordinate your care. Established in 2021 and continually evolving, our service is designed to help patients who may struggle to access healthcare through usual routes due to disability, complex long-term conditions, frailty, social challenges, or a sudden health crisis.

Who Can Benefit?

Our Proactive Care Service is designed for patients who:

Have long-term or complex health conditions, including frailty.
Are managing multiple health challenges or complex social issues.
Have been recently discharged from hospital or experienced a fall.
Are acutely unwell and require extra coordinated support.
Need palliative or end-of-life care.
Experience barriers to accessing traditional healthcare services.

What We Offer

Proactive Care Clinicians

Our Proactive Care Clinicians support patients with both long-term health conditions and urgent medical needs. They care for housebound patients who need ongoing condition management, as well as those who are more acutely unwell and require close monitoring, such as patients on our virtual ward.

They may call or visit you at home to:

Monitor and manage long-term conditions such as diabetes, heart disease, or respiratory illnesses.
Carry out detailed assessments to plan and manage your care in line with your personal health goals.
Conduct annual health checks to ensure your condition is being managed effectively.
Review and adjust medications to ensure they remain safe and appropriate for your needs.
Provide clinical support when your health changes, responding quickly to prevent deterioration or unnecessary hospital admissions.
Administer vaccinations for housebound patients, including seasonal flu, COVID-19, and RSV vaccines.

Whether providing routine care or responding when you are more unwell, our Proactive Care Clinicians ensure you receive the right level of support, at the right time, in the comfort of your home.

Care Coordination

Our Care Coordinators ensure that patients under the Proactive Care Team receive well-organised, timely, and effective support. They work closely with GPs, proactive care clinicians, and external services to make sure your care is well-coordinated.

They:

Triage referrals into the team and ensure patients receive the right level of support.
Make welfare calls to check in with patients and identify any new needs.
Arrange home visits when needed.
Support hospital discharges, ensuring you have a follow up plan in place after your return home.
Facilitate access to key services, including district nursing, Hospital at Home, social care, physiotherapy, occupational therapy, and palliative care.

For particularly vulnerable patient, such as those with complex health conditions at risk of deterioration, memory impairment, or palliative care needs, our Care Coordinators provide extra support. This may include a direct line for quick access, arranging urgent care if needed, and ensuring a rapid response to changes in health or social circumstances. They also bring together different professionals in multidisciplinary team discussions to ensure your care is fully joined-up and responsive to your needs.

Cancer Care Coordination

A cancer diagnosis can be overwhelming, and knowing where to turn for support is important. Our dedicated Cancer Care Coordinator is here to offer a listening ear, emotional support, and practical help in coordinating your care within the GP practice.

They can support you by:

Providing a single point of contact at the practice, so you know who to reach out to with any concerns.
Offering emotional support to you and your family throughout your cancer journey.
Helping to arrange cancer care reviews with your GP, ensuring your needs are regularly assessed.
Coordinating support within the practice, including follow-ups, medication reviews, and referrals to other services if needed.
Signposting to local and national cancer support services, such as support groups, wellbeing resources, and financial advice.

Our Cancer Care Coordinator works alongside your GP and the Proactive Care Team to ensure you receive the right support when you need it. Whether you have questions, need help arranging care, or just someone to talk to, they are here to support you at every stage.

Palliative & End of Life Care Support

We provide compassionate, coordinated support for patients and their families during difficult times, ensuring both clinical and social care needs are met.

Social Prescribing

Health is about more than just medical care - everyday challenges can affect your wellbeing. Our Social Prescribers are here to listen to your concerns and connect you with services, activities, and community groups that can support your overall wellbeing.

They can:

Help with social isolation and loneliness: Connecting you with local groups, befriending services, and social activities.
Signpost to financial and housing support: Advising on where to get help with money concerns, benefits, or housing issues.
Provide information on local groups, activities, and courses: Helping you access hobbies, learning opportunities, or community initiatives.
Offer practical and emotional support: Helping you find the right support for your wellbeing.

Our Social Prescribers work alongside your GP and the Proactive Care Team to provide non-medical, personalised support tailored to your needs.

Integrated Neighbourhood MDT

The Proactive Care Team is part of a local Integrated Neighbourhood Team, supporting patients with complex physical, mental health, or social care needs. This team brings together health and social care professionals to ensure patients receive the right support from the right services.

This may include:

Patients facing significant social challenges or safeguarding concerns.
Those requiring input from multiple services, such as community therapy, mental health teams, or adult social care.
Patients with complex medical needs that require a joined-up approach.

By working together, we help ensure patients receive well-coordinated care that meets their needs in a safe and effective way.

What to Expect

When you are referred to the Proactive Care Team, we will assess your needs and arrange the most appropriate support for you. This could include:

A home visit from a nurse or social prescriber to check on your health, wellbeing, and any additional support you may need.
A welfare call from a care coordinator to see how you're doing, offer advice, and help arrange further care.
Referrals to other services, such as district nursing, physiotherapy, occupational therapy, social care, or mental health support.
A discussion at one of our multidisciplinary team (MDT) meetings, where different health and social care professionals work together to plan the best care for you.

The type and frequency of support will depend on your individual needs, ensuring you receive the right help at the right time.

How to Access Our Service

Referrals to the Proactive Care Team often come from a GP or another member of the practice team. Patients may also be identified through hospital discharge letters, external services such as district nurses or social care teams.

However, if you feel you would benefit from our support, you can also request help directly by speaking to a member of our reception team.

Our Proactive Care Service is completely free of charge, and we are committed to providing high-quality, coordinated care that meets the diverse needs of our patients and community.

Functional Cookies

3rd Party Cookies