Pro-Active Care model – Dr Tuan Nguyen

When I was a GP in Liverpool, I developed the Pro-Active Care (PAC) model. The foundation of the model is to place the individual at the centre of all decision making. Individuals and their carers/families are supported by a wraparound neighbourhood clinical team to become experts in their particular long term condition(s).

The neighbourhood team assesses the person and their family and facilitates the implementation of a shared plan. This can include things such as the installation of a bath lift or extra handrails to enable the individual to retain independence, or more clinical aspects such as optimisation of medications, and a deeper understanding of their particular long condition. Individuals complete a 12 week programme that helps them to become experts on their condition(s) and be able to self manage and sometimes challenge medical professionals intelligently and confidently.

These individuals were monitored from their enrolment onto the programme in January 2011 until now. Utilising the EQ5D questionnaire, we were able to assess their self reported health at the beginning and end of the programme. This showed remarkable improvement across the 6 domains:

  1. Mobility: 3 fold increase
  2. Self care: from 40% to 70% at programme end
  3. Usual activity: >2 fold increase
  4. No pain or discomfort: >2 fold increase
  5. No anxiety/depression: improved from 40% to 70%
  6. Your health today: increased from 38% to 69%, an increase of 83%

When I moved to Folkestone in Kent, my partners knew about my work in Liverpool and encouraged me to develop it in that area. The Liverpool pilot yielded valuable learning points for me. In Kent, the clinical team was integrated along with the health trainers, but there was no representation from social services or mental health to make it truly integrated.

To make the PAC model work optimally in line with the National LTC QIPP (Long Term Conditions Quality, Innovation, Productivity and Prevention) programme, we needed to get buy-in from all stakeholders. High level buy-in from local MPs, Kent County Councillors and Kent Community Health Trust was vital and achieved through my participation and presentation at the Kent Health Commission board. South Kent Coast Clinical Commissioning Group (SKC CCG) buy-in was achieved through presenting to a locality meeting. Through this high level work, PAC became part of SKC CCG’s commissioning intention for 2012/13.

This high-level engagement enabled us to bring together social and community services, as well as primary care, to discuss integrated working for the benefit of our residents. Unfortunately, at the time of writing this, we have been unable to obtain full engagement from mental health services, but we will continue to work to accomplish this. PAC has rolled out to a neighbourhood of 4 GP practices in Folkestone and we have plans to expand it further.

Running in parallel with PAC will be the development of our in-house combined predictive tool. This will enable the early detection of an individual’s increasing risk for hospitalisation so that we can support these individuals at a much earlier time, empowering them to better manage and modify factors that could adversely affect their future wellbeing, potentially avoiding hospitalisation.

In summary, the key aspects of the PAC pathway are:

  1. Person-centred care: the patient and their carer/family will fully participate in discussing and formulating their individual health plan
  2. Integrated neighbourhood teams
  3. Multidisciplinary team meetings: no-blame peer review and optimisation of care with the individuals driving the agenda
  4. Risk stratification: upstream identification of those with increased risk
  5. Self management: through education and support

Acknowledgements

  • Ann Nolan – Tailored Care clinical lead, Liverpool Community Health
  • Lisa Hammond – Tailored Care clinical lead, Liverpool Community Health
  • Sophie Kelly – North Mersey Health Informatics Service
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