Does proactive care in care homes improve survival? A quality improvement project.

Background: NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered.

Aim: To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents.

IT-assisted comprehensive geriatric assessment for residents in care homes: quasi-experimental longitudinal study.

Background: Frailty interventions such as Comprehensive Geriatric Assessment (CGA) can provide significant benefits for older adults living with frailty. However, incorporating such proactive interventions into primary care remains a challenge. We developed an IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP).

The Pathfields Tool: a frailty case-finding tool using primary care IT-implications for population health management.

Background: older people living with frailty benefit from targeted interventions which improve health and independence. However, it has been challenging within primary care to systematically identify patients living with frailty.

Methods: primary care IT was re-programmed to create a 'Pathfields High Risk Cohort' (PHRC, patients felt likely to have undiagnosed frailty) and invite clinicians to opportunistically assess and diagnose frailty.