Proactive Care

Proactive Care [PC]:   

Actions 2023:

  • Proactive Care aggregate dashboard completed and demonstrated to Workstream Leads in January.
  • Frailty case-finding tool developed and demonstrated to Workstream Leads in January.
  • It is anticipated that the tools will be tested in PCNs and will be available by the end of March 2023 – however, this will be subject to external assurance, given the dashboards are deemed Class 1 medical devices. Risk captured on the Ageing Well Highlight Report.
  • A Steering group for the Year of Care/Proactive Care programme has been established and the following PCNs have been recruited -Carlisle Healthcare, Keswick and Solway.  Kick off events for each PCN have taken place and have covered – coherence around the programme, case for change and engagement, key principles and some mapping of processes along with development of local action plans.


Actions 2022:

  • Workplan established
  • Baseline mapping for current Proactive Care delivery in ICP and places – to continue
  • Establishing working groups around finding (Ageing Well PHM tool linking to HI toolkit), supporting (PCSP tools) and measuring what matter (ICARE outcomes framework).
  • Set up a PCN reference group
  • Test out PC ‘enabling’ tools for population segmentation
  • Test out PC outcomes framework
  • Test out PCSP with UPC colleagues via Year of Care pilots
  • Explore and test out digitalized PCSP across the region via GNCR/HIE focusing on End of Life  and palliative care
  • Establish an ICS Proactive Care plan for Q3 2022

See diagram structure.


A case-finding dashboard is being developed in RAIDR that will enable practices to search for patients based upon the national Proactive Care guidance. This will include the ability to identify patients with frailty, multiple long term conditions, people who live within the most deprived communities, have been or who are at risk of attending A&E and/or who have Ambulatory Care Sensitive Conditions. The search tool will also enable searches to be refined based upon demographics including age, gender and ethnicity.

Supporting / Year of Care Pilot

Work is underway in 2 PCNs in North Cumbria to design proactive care pathways using the Year of Care model of Personalised Care and Support planning to coordinate care for people living with LTC and frailty. This includes looking at how practices organise care, how people are invited into the programme and are prepared for the process, use of IT templates to structure and streamline assessments, the care planning conversation itself and how a person centred care plan is available for the person and within the healthcare record. This includes clarifying what happens at each stage in the process and how different professionals within the MDT contribute, including identifying competencies and  training needs of professionals in new roles.