Case identification

The nationally developed Anticipatory Care Planning Dashboard identifies people who match the above criteria at the Primary Care Network (PCN) level. By applying location and demographic filters in the dashboard, you can decide which groups of people in your area could benefit the most from anticipatory care.

The dashboard is available via The Foundry. The onboarding guide will walk you through the three-step registration process: registering for an Okta account, applying for access and setting up two-factor authentication.

The user guide explains how to apply the various filters to identify suitable groups of people in your area.

Once you have used the dashboard to identify people who could benefit from anticipatory care, you can then further assess their suitability using guidance and toolkits specific to their medical condition(s).

Useful documents:

NHS National Data Platform Foundry Onboarding Guide

Anticipatory Care Planning Dashboard User guide

Here is an example checklist to identify people who are vulnerable:

• Someone with increasing clinical complexity or psychosocial needs
• Someone who frequently calls or uses services
• Someone who currently uses two or more of the following services:
  • Frailty
  • Mental Health
  • Learning Disability
  • Safeguarding Concerns (adult or child)
• Someone with a social or lifestyle component to their health needs

The Vulnerabilities Multi-Disciplinary Teams: Standard Operating Procedure offers guidance for carrying out the frailty review which you can use as a basis to create your own version.

The following checklist can be used when carrying out a welfare or frailty review.

A person can be identified as frail when they:

• Are over 65 years of age and meet at least one of the below criteria:
  • Frequent falls
  • Sudden change to mobility
• Have been diagnosed with:
  • Dementia or acute confusion
  • Parkinson’s
  • Four or more long-term conditions

• Score five or more on the Rockwood Frailty Scale

The Frailty Service: Standard Operating Procedure offers guidance for carrying out this review which can be used as a basis to create your own version.

The trips and falls checklist is useful for assessing whether someone is at risk of falling. It forms part of the Steady Steps for Staying Active for Life guide.

The Pathfields Medical Group in Plymouth uses a simple and time-saving software tool to diagnose and log frailty in a patient.

When a GP is consulting a patient who is at risk of having undiagnosed frailty, a message pops up, inviting the clinician to diagnose frailty by severity.

At the push of a button, the GP can then quickly code the patient according to their circumstances, such as whether they are housebound, have supported living or live in a care home.

The tool also prompts a re-assessment of the patient’s frailty status after 18 months.

Find out more:

The Pathfields Tool: How to Make the Frailty ID Software work in Systmone

A Brief Guide Diagnosing Frailty in Primary Care and Using the Pathfields Tool to case-find frailty in your practice population