Proactive care: providing care and support for people living at home with moderate or severe frailty


This guidance is for integrated care boards (ICBs) and provider organisations involved in the design and delivery of proactive care.

Proactive care is personalised and co-ordinated multi-professional support and interventions for people living with complex needs. Many systems are already delivering proactive care.

The specific aims of proactive care are to improve health outcomes and patient experience by:

  1. delaying the onset of health deterioration where possible
  2. maintaining independent living
  3. reducing avoidable exacerbations of ill health, thereby reducing use of unplanned care.

This guidance supports a more consistent approach to proactive care across England for people living at home with moderate or severe frailty, in line with the latest evidence and best practice. Proactive care for this group is not a new service or pathway, and this is simply a guide to using existing resources to support this defined group within local priorities.

Frailty is increasingly common – more than one in 10 people over the age of 65 (British Geriatrics Society, 2023) and up to half the population aged over 85 (Clegg et al, 2013) live with frailty, but frailty is not an inevitable part of ageing. The onset or progression of frailty can be slowed by taking a biopsychosocial approach and putting in place personalised and preventative measures that address a person’s range of needs in a timely way, enabling them to live independently and healthier for longer.

The increasing numbers of people with frailty have significant implications for health and care provision. Where early signs of frailty in people are not recognised and supported in the community, many subsequently present in crisis (British Geriatrics Society, 2023). Around 47% of hospital inpatients aged over 65 are affected by frailty (Doody et al, 2022) and this costs wider UK healthcare systems around £5.8 billion per year (British Geriatrics Society, 2023).

ICBs hold overall responsibility for ensuring implementation of proactive care, as part of an overall local plan to support people living with frailty. Working with relevant partner organisations, primary care networks (PCNs) will be well placed to identify the proactive care population cohort, with multi-professional support and interventions delivered through integrated neighbourhood teams. Those teams will likely include professionals from primary care, community services, mental health, secondary care and the voluntary sector.

The importance of delivering proactive care is set out in NHS England’s Mandate, the 2023/24 Winter Plan, the Major Conditions Strategy, GP Contract, NHS England Delivery plan for Recovering Access to Primary Care and the Fuller Stocktake report. Ensuring consistent successful delivery across the country will contribute to recovering urgent and emergency care services.

Core components

Building on the evidence and best practice from the NHS and internationally, we have identified five core components of the proactive care approach:

  1. Identifying the target cohort for whom there is the greatest potential impact on health and system outcomes
  2. Carrying out holistic assessments, such as a Comprehensive Geriatric Assessment
  3. Developing a personalised care and support plan
  4. Delivering co-ordinated multi-professional interventions to address the person’s range of needs
  5. Providing a clear plan for continuity of care, including an agreed schedule of follow-ups.

1. Case identification

To ensure cost-effective delivery and impact for patients, it is important to prioritise multi-professional resource where there is the greatest evidence that delivering proactive care improves health outcomes and experience and reduces overall health and care system usage. National data analysis and evidence from local systems indicates people living with moderate or severe frailty are a priority.

Several tools are available to support case identification for people with moderate and severe frailty. For example, the second version of the electronic frailty index (eFI2) will better discriminate frailty and risk of adverse outcomes. The eFI2 has been registered with the MHRA as a Class I medical device and will be made available through primary care electronic health record systems and can also be provided directly to ICBs and PCN teams as needed. Clinical validation will also be required using tools such as the Rockwood frailty scale.

To further prioritise this cohort, systems should analyse their unplanned care datasets to identify locally which patient cohorts could have been supported earlier in the community through proactive multi-professional support and with this their health exacerbations avoided. Example indicators include:

  • frequent use of primary care or unplanned care
  • readmissions into acute care within 30 days of discharge
  • living alone with a limited social network
  • people who present with loneliness
  • recent death of someone close to the individual
  • taking multiple medications (polypharmacy).

Systems should also consider how patient contacts and health interactions could be used to identify people who would benefit from proactive care. These interactions are likely to include annual health checks, annual single condition reviews, following discharge from hospital, virtual wards or urgent community response services, or following unpaid carer assessments.

When considering the cohorts for proactive care, systems should be aware that people in socio-economically deprived areas are likely to develop frailty around 10 years earlier than those in areas of less deprivation. Data in healthcare systems may also be limited for people from health inequality groups, as their records may be incomplete. To mitigate exclusion of health inequality groups from proactive care, outreach to specific population groups will likely be required.

2. Holistic assessment

Central to providing more proactive care is for a healthcare professional to work with people and their carers to understand the full range of health, social and self-care needs, using a holistic assessment based on shared decision-making principles.

It is recommended that evidence-based holistic assessment tools are used such as the Comprehensive Geriatric Assessment toolkit. Other electronic holistic assessment tools are available at a local and international level, e.g. the InterRAI Comprehensive Assessment Instruments.

The holistic assessment should cover:

  • personal and social circumstances, including socio-cultural factors
  • past medical history and current health and wellbeing needs
  • mental capacity assessment, particularly around care planning and interventions where appropriate
  • consideration of assessment under the Care Act 2014 and eligibility for NHS Continuing Healthcare
  • consideration of carer assessment and a carer support plan.

3. Personalised care and support planning

The next step in proactive care will be clear care planning. The comprehensive model of personalised care recommends that following the holistic assessment, a personalised care and support plan (PCSP) is co-produced with the person and the person facilitated to also involve those who are important to them, including family, friends and/or carers, if they wish to do so. Input from a range of professionals will be needed to develop the PCSP.

A PCSP sets out the person’s health and wellbeing goals and interventions to be taken and empowers people to play an active role in their health and care. The care plan will be particularly important where people have multiple health and care needs. So as not to overwhelm the person and to make the plan feasible, interventions should be prioritised based on their potential impact and people’s preferences.

It may be appropriate to offer advance care planning, using universal principles, particularly for people identified to have palliative and end of life care needs.

4. Co-ordinated and multi-professional working

A range of clinicians and professionals are likely to be needed to support decision-making and care for people with moderate to severe frailty. Multidisciplinary teams may be formed to support this way of working, with flexible membership to ensure the required professional expertise can be sought when needed.

The ambition is for ongoing support for this population groups to be delivered through integrated neighbourhood teams (INTs). People with more complex needs often receive care from multiple services, and the INT approach aims to pull together those leading services into a single team, to better co-ordinate overall care and reduce the need for slow and bureaucratic formal referral processes.

Multi-professional can mean registered and non-registered health and care professionals from a range of organisations, including primary care, community care, mental health, secondary care, social care, housing, and voluntary, community and social enterprise (VCSE) organisations. INTs should work with VCSE organisations to ensure the person can be offered appropriate interventions and support; for example, if social isolation is highlighted during the holistic assessment and PCSP, then local VCSE organisations are likely to be able to provide social support for the individual.

A named co-ordinator who provides a clear point of contact for advice is an important element of proactive care. Effective care co-ordination will help individuals navigate care across the health and care system and support them when receiving support from a range of services. Care co-ordination will also ensure service provision is co-ordinated, using a shared health and care record, and working to one PCSP. A care co-ordinator may be a member of the multi-professional team or an Additional Roles Reimbursement Scheme funded care co-ordinator. The Workforce Development Framework for Care Co-ordinators provides guidance for care co-ordinators in the NHS and those employing them. It sets out professional standards and competencies, and gives guidance on supervision, training and continuous professional development.

A range of evidence-based interventions and support should be considered as part of co-developing the PCSP. These interventions and support may need to be prioritised or sequenced for maximum impact. Examples of interventions that may be utilised include structured medication review and management support, multifactorial falls risk assessment and action planning, cognitive assessment, treatment, care and support.

For exacerbations of ill health, the INT should have direct access to urgent provision, preferably in the community where appropriate, including urgent community response and virtual wards. Should an individual receiving proactive care be admitted to hospital, the INT should work with secondary care to support timely discharge, including through the use of intermediate care.

5. Continuity of care

Continuity of care will be a core element of effective proactive care. It is defined as the ongoing relationship a person has with a clinical team or member of a clinical team, and the co-ordinated clinical care that progresses as the person moves between different parts of the health service: relational, management and informational continuity (RCGP, 2018).

Continuity of care enables personalised care, improves care quality, boosts a person’s confidence in medical decision-making, and fosters greater job satisfaction for health and care professionals.

A clear plan for follow-up based on individual need should be developed for each person, and flexibility built into this in case follow-up is needed sooner than expected.

Overall clinical accountability for people receiving proactive care needs to be clear. In many cases the responsible clinician will be a named GP, but in some local areas it may be a community geriatrician or advanced clinical practitioner.


Implementation of proactive care will vary locally, dependent on the population and on the provider landscape.

Three key enablers for the implementation of proactive care have been identified:

  1. Flexible workforce.
  2. Shared care record.
  3. Clear accountability and shared decision-making.

1. Flexible workforce

The workforce is central to delivery of proactive care. It is important to ensure a multi-professional team functions with sufficient capacity, the right training and expertise, with the ability to draw on other professions as needed and respond to the needs of a local population.

Proactive care will need to be supported by a shared workforce plan between partner organisations involved in the delivery of proactive care and appropriate training for staff.

2. Shared care record

Effective design and delivery of proactive care is built on strong digital infrastructure and connected data and enabled by Population Health Management expertise. Central to this infrastructure will be the shared care record, accessible by all authorised health and care providers involved in providing multi-professional support.

3. Clear accountability and shared decision-making

The delivery of proactive care will be heavily dependent on local partnership working between NHS providers, local government and the VCSE sector. ICBs should encourage joint executive leadership and system agreements across partner organisations, through shared decision-making and governance. This governance should include agreement on health and system outcomes and consider alignment of commissioning and contracting arrangements.


Publication reference: PRN00391