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Change 2: Target and tailor interventions and support for those most at risk

Address the most pressing clinical and social barriers, identified by data and insight, that put people at risk of a preventable admission through dedicated services.

This change supports Goal 1: Prevent crisis.

Making it Real statements

I feel safe and am supported to understand and manage any risks."

We work with people to manage risks by thinking creatively about options for safe solutions that enable people to do things that matter to them."

Tips for success

  • Having formed an integrated view of those at high risk of preventable admissions, maintain and use local lists and registers of at-risk cohorts to offer regular timely screenings and interventions. Take account of when seasonal or time-based responses may be needed, such as ‘flu or months when falls-related admissions increase.
  • Make the use of screening tools, such as the Frailty Index, part of the pathway used to identify individuals at risk. Support more integrated care for people living with frailty by developing enriched summary care records.
  • Provide a single point of access for health and care staff to make referrals for community interventions. Where possible these should be trusted referrals which lead straight to intervention, to avoid the person repeating their situation and so that they can be coordinated around the individual and their family and/or carer(s).
  • Ensure collaboration between pharmacists and other community services to support medicine reconciliation and review.
  • Early use of technological interventions and solutions, where appropriate, can promote independence for longer and so delay or remove the need for community services, such as homecare, altogether. Develop a process to introduce assistive living equipment and digital tools to support self-management as soon as possible after the need is identified.
  • Use telehealth and telecare to support the treatment and monitoring of people at home to anticipate potential problems or crises. Embed the use of digital technology, where appropriate, such as remote monitoring and video consultations, across the pathway from home to hospital or care home, and then the transition back to community.
  • Ensure that housing needs are considered. Ready access to an appropriate range of housing related support can help people stay in their own home as well as support those with no or inappropriate housing.
  • The NHS Enhanced Healthcare in Care Homes framework sets out the key actions to support health and wellbeing for care home residents.
  • Where telecare is used as a reablement intervention, consider expanding this offer to include other types of telehealth digital monitoring devices. Use trusted assessment to prevent delays in assessment. Reablement can be used as a preventative intervention.
  • Unlocking the preventative benefits of care technology requires a good understanding of the digital and data capabilities of your local care technology offer. What is your approach to using data from devices to drive real-time decision making or to anticipate and prevent crises? How will the data collected from technology be analysed and used to inform care planning and reviews or reassessments?
  • Ensure that care plans for those at the highest risk include regular prompts for timely screenings and other forms of preventive care. Consider also whether a safeguarding plan is required. 

Examples of emerging and developing practice

Supporting materials

NHS Quick Guide: Health and Housing, Provides tips and case studies to support health and care systems, 2016
Help with home adaptations: improving local services: A ‘Home Adaptation Challenge Checklist’ for older people’s forums and other stakeholders, Care and Repair, 2019.
NHS Frailty resources including the NHS Rightcare Frailty Toolkit, June 2019.
What is Anticipatory Planning Toolkit Healthcare Improvement Scotland’s webpages to help planning for the future.
Safeguarding resources: LGA and ADASS Safeguarding Network web page.
Transforming out-of-hospital care for people who are homeless: Support Tool and Briefing Notes complementing the High Impact Change Model for transfers between hospital and home, King’s College, November 2019.
LGA Care Technology Planning Resource, a practical tool to enable councils to review their local care technology approach in a structured way and to act as a catalyst for further activity, November 2020.

To request a PDF copy of this resource, please email [email protected].