Cygnet Primary Care Network (BS 5)
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Anticipatory care helps people to live well and independently for longer through proactive care for those at high risk of unwarranted health outcomes. Typically, this involves structured proactive care and support from a multidisciplinary team (MDT). 

It focuses on groups of patients with similar characteristics(for example people living with multi-morbidity and/or frailty) identified using validated tools (such as the electronic frailty index) supplemented by professional judgement, refined on the basis of their needs and risks (such as falls or social isolation) to create a dynamic list of patients who will be offered proactive care interventions to improve or sustain their health.

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Our Aims

  • Benefitting patients with complex needs, and their carers, who are at risk of unwarranted health outcomes by enabling them to stay healthier for longer, with maintained or improved functional ability and enjoy positive experiences of proactive, personalised and self-supported care.
  • Reducing need for reactive health care for specific groups of patients and supporting actions to address wider determinants of health.
  • Delivering better inter-connectedness between all parts of the health system and the voluntary and social care

Anticipatory care is intrinsically linked to population health management models developing and already in place in systems across the country. The service focuses on the “rising risk population”, comprising those with multiple long-term conditions and/or frailty, who may have underlying risk factors like unhealthy lifestyles, behavioural risks, social isolation or poor housing.
Addressing many of these risk factors will require non-clinical interventions and strong working relationships with local voluntary, community and civic groups, as well as system public health teams