Proactive care for frailty patients

Integrated Community Care Teams in Wirral

Wirral’s proactive care programme is bringing together the teams who support people with frailty and chronic disease to provide increasingly personalised and holistic care - with community trust frailty nurses now working as part of an integrated team.

Following referral via either a GP practice or community team, an initial visit is carried out by a lead clinician before a care plan is developed and agreed.

As patients with complex ongoing needs typically benefit from continuity of care, the whole team - including the community trust-employed staff - use the GP patient record for all clinical documentation.

Initial findings show that the service is reducing both GP appointments (15%) and hospital admissions (25%) for patients who are supported via the programme when comparing service use prior to the programme to three months after first contact with the team.