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Proactive Care Models in PCNs: Identifying High-Risk Patients Before Crisis
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- What is a proactive care model in a PCN?
- How do you build a proactive care model?
- Which patients are most likely to benefit from proactive care?
- How can PCNs identify high-risk patients?
- Why is risk stratification alone not enough?
- What role can clinical pharmacy teams play in proactive care?
- How should PCNs and Practices measure whether proactive care is working?
A proactive care model PCN approach helps Primary Care Networks identify people whose health is beginning to deteriorate, intervene earlier, and coordinate care before avoidable hospital admissions or crisis occur. The strongest models combine population health management, clinical judgement, and multidisciplinary working rather than relying on risk scores alone.
As neighbourhood healthcare develops across England, proactive identification and continuous support are becoming increasingly important for PCNs managing complex populations.
A proactive care model is not just a risk score or a patient search. It is an operating model that connects data-led identification with clinical validation, personalised care and support planning, multidisciplinary team intervention, and ongoing continuity.
Key Takeaways
- Clinical validation is vital: Data extraction starts the process but does not replace clinical review.
- Connected processes: Effective proactive care connects identification, holistic assessment, personalised planning, multidisciplinary team intervention, and continuity.
- Realistic targeting: Cohorts should be based on local need and a realistic intervention, not risk score alone.
- Measure what matters: PCNs and Practices should measure patient outcomes, continuity of care, and equity – not just activity.
A proactive care model PCN strategy ensures that high-risk patients are not just identified, but actively managed. Rather than waiting for a patient to present with an acute issue, the PCN uses data to anticipate needs and wrap support around the individual.
What is a proactive care model in a PCN?
To understand the difference, consider how this approach compares to traditional models:
| Reactive Care | Proactive Care |
| Responds to deterioration | Identifies risk early to improve patient outcomes |
| Hospital admission | Preventive targeted intervention |
| Episodic | Continuous |
| Single episode | Coordinated multidisciplinary team |
| Crisis driven | Planned |
How do you build a proactive care model?
To implement this effectively, PCNs and Practices should follow a structured seven-step process.
- Define the patient cohort Start with a patient group that has a clear intervention pathway rather than trying to identify every high-risk patient at once.
- Combine risk signals Use multiple data points, such as frailty scores, long-term conditions, and emergency department attendances, to build a complete picture.
- Validate the data clinically Clinical teams should review the cohort before any intervention begins to ensure the risk is current and the patient will benefit.
- Complete a holistic assessment Look beyond individual disease targets to assess functional ability, medicines adherence, and social circumstances.
- Agree a personalised care plan Develop a personalised care and support planning approach that focuses on what matters to the patient.
- Coordinate multidisciplinary intervention Assign clear roles across the team to ensure the patient receives the right support from the right professional.
- Maintain continuity and review Establish clear follow-up timescales and named coordinators to ensure the patient does not fall through the gaps.
Which patients are most likely to benefit from proactive care?
The most effective proactive care model PCN approaches avoid suggesting one universal list. Cohort identification should reflect local need, capacity, and available interventions. Starting with a broad list of high-risk patients can create more work than the team can safely absorb.
| Potential Cohort | Why the Group May Benefit |
| Moderate or severe frailty | Greater risk of adverse outcomes, loss of independence, and hospitalisation |
| Multiple long-term conditions | Complex treatment burden and fragmented care |
| Frequent unplanned care users | Existing pattern of deterioration or crisis use |
| Polypharmacy patients | Higher potential for adverse events and treatment burden |
| Housebound patients | Reduced access to routine reviews and preventive support |
| Recent hospital discharge | Elevated risk during transitions between services |
| Care home residents | Complex needs requiring coordinated multidisciplinary oversight |
When defining cohorts, it is essential to consider health inequalities. A digitally convenient approach may disproportionately reach patients who are already engaged.
How can PCNs identify high-risk patients?
Identifying a proactive care model PCN cohort requires more than just running a search. Useful signals for proactive identification can include frailty scores, number of long-term conditions, emergency department attendance, and medicines burden.
While tools like EMIS searches for population health management are essential for gathering data, risk stratification must be supported by clinical judgement. A risk algorithm predicts an outcome based on the data available, but it does not fully explain the cause of the risk or the most appropriate intervention.
Why is risk stratification alone not enough?
Data alone is not enough because electronic tools depend on accurate and current coding. They may under-identify people who engage less with primary care. A clinician must review whether the risk is current, whether the person is already receiving suitable support, and whether another pathway is more appropriate.
High risk scores do not always equal high benefit from routine interventions. Identifying hundreds of complex individuals without staff capacity or an intervention pathway can create an unmanaged backlog. This is why a complete proactive care model PCN framework is required.
What role can clinical pharmacy teams play in proactive care?
Clinical pharmacy teams are central to a successful proactive care model PCN strategy, supporting this approach by focusing on medicines safety and long-term condition management.
Clinical Pharmacists
Clinical Pharmacists lead on complex clinical interventions. They support the model by delivering structured medication reviews for targeted cohorts, identifying medicines associated with falls or acute kidney injury, and resolving polypharmacy risks whilst deprescribing if clinically appropriate.
Pharmacy Technicians
Pharmacy Technicians provide essential operational and technical support. They drive data quality, assist with cohort identification, support post-discharge medicines reconciliation, and monitor the completion of agreed actions.
How should PCNs and Practices measure whether proactive care is working?
A mature population health management approach challenges PCNs not to measure success solely by the number of patients placed on a register.
| Area | Example Measures |
| Process | Holistic assessments completed, care plans agreed, named coordinators assigned |
| Medicines | Medicines optimisation reviews completed, risks resolved |
| Clinical Outcomes | Falls, exacerbations, condition-specific indicators |
| Continuity | Contacts with named clinician or small team |
| Patient Experience | Confidence, treatment burden, experience of coordination |
| Healthcare Utilisation | Unplanned admissions, emergency attendances, urgent GP contacts |
| Equity | Differences in access and outcomes between population groups |
To align with the shift towards integrated neighbourhood teams, PCNs must demonstrate how their proactive care model PCN approach delivers genuine continuity of care and improves patient experience.
Expert insight from Adeem Azhar, qualified Clinical Pharmacist and CEO
The real value of proactive care comes after the patient has been identified through coordinated intervention, medicines optimisation and continuity of care. PCNs and Practices need a clear route from data to clinical review, personalised planning and accountable follow-up. Without that operating model, risk stratification can simply create another list for already stretched teams.
Adeem Azhar, MPharm, IPres
Co-Founder and Chief Executive Officer – Core Prescribing Solutions
Qualified Clinical Pharmacist
FAQs
Looking for support with your PCN pharmacy workforce?
If your PCN wants to strengthen proactive care through medicines optimisation, structured medication reviews and additional clinical pharmacy capacity, our Clinical Pharmacists and Pharmacy Technicians can integrate with your existing team to support risk-based care.
