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Integrated working to address frailty needs: Bradford District and Craven Health and Care Partnership




NHS Confederation

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This case study illustrates how the delivery of an integrated approach has led to significant health and social improvements among frail and older people within Bradford District and Craven. The Proactive Care Team (PACT) was established, working with partners to provide holistic, person-centred care (and encourage self-care) for people with moderate frailty, to prevent it from becoming severe. Key benefits and outcomes include: the transformation of the lives of more than 300 frail and older people; effective identification through data of patients most at risk; reduced gaps in care and risk through partnership working; improved navigation for patients through health and care services (considering health, care, socio economic needs); and reduced duplication through collaboration, ensuring patients are seen at the right place at the right time. The case study also reports how obsracles were overcome and key takeaway tips. (Edited publisher abstract)

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