Proactive Care Team

The Proactive Care Team is a team of GPs, Nurses, Care Coordinators and Social Prescribers who work alongside a patient’s usual GP. The team work proactively to improve access to healthcare for the practices highest need patients and their families, and to those with a barrier to accessing health and social care independently through the usual route.  

The Proactive Care Team support patients and their families through both short-term health and social care crises, and longer-term frailty, chronic disease management and end of life care.  This additional service within the practice was created in 2021 and has been continuously developing and expanding in scope.  

Click here to meet the team

What sort of patients is the service aimed at?  

The patients who benefit from the service are patients with a physical or psychological condition that prevents them from accessing health or social care through the usual routes. This might include those who are frail, elderly, housebound, with complex comorbidities, with a learning disability, with complex social difficulties.  

Social Prescribing service

Our team of Social Prescibers are here to help you look after your health and feel better. Lots of things in your everyday life can affect your health and get in the way of making the changes you want to make. Instead of giving you a prescription for a medicine, your Social Prescriber will work with you to create your own social prescription. This will help you to access activities and support that will improve your health and enjoyment of life. Whatever worries or questions you may have, we are here to listen and will help you get the advice and support you need. 

Care Coordination

Our Care Coordinators provide extra time, capacity, and expertise to support patients in preparing for clinical conversations or in following up discussions with primary care proffessionals. They work closely with the GP's and other primary care colleagues (Social Prescriber and Health and Wellbeing Coach) with the primary care network (PCN) to identify and manage a caseoad of identified patients, making sure that appropriate support is made available to them and their carers (if appropriate), and ensuring that their changing needs are addressed. They focus on the delivery of personalised care to reflect local PCN priorities, health inequalities or at risk groups of patients. They can also support PCNs in the delivery pf Enhanced Health in Care Homes.

What support can I get?

Our Proactive Care Team can help support you with a range of issues, including:

  • Long term health conditions
  • Social isolation
  • Emotional wellbeing
  • Healthy lifestyle choices inc diet and nutrition
  • Getting out and about
  • Life changing events such as birth, retirement, bereavement
  • Loss of confidence/purpose
  • Poor health linked to housing or housing conditions
  • Accessing work, training and volunteering

How to book an appointment?

You can book an appointment by speaking to a member of our reception team and requesting a session with our Social Prescribers. Your GP, or other members of the practice team, may also refer you to the service if they feel it would be helpful.

Does it cost anything?

 No, our service is free.