Proactive Management of Admission Avoidance Local Enhanced Service

Description

Support the proactive management of long-term conditions. Lot 1: Description of the services to be provided: Embed the assessment of frailty (utilising the Clinical Frailty Scale) within all long term condition review appointments (with onward referral to / delivery of evidence-based interventions to address the person's individual needs). Utilise the predictive risk algorithm and develop a risk stratified timetable setting out how all patients on the register will be reviewed across the year the practice signs up to the Scheme, starting with those patients assessed as at highest risk. Deliver reviews which will include anticipatory care planning, structured medication review, falls risk assessment, nutritional assessment, vaccination and any holistic support that could be provided via the services within the Integrated Neighbourhood Team. Where any elements of these reviews (e.g. vaccination / falls assessment) are not delivered an exception reason must be provided, for example patients providing informed dissent. Support the work of the care navigation service and the delivery of high quality multi-disciplinary team working within the Integrated Neighbourhood Team actions that follow. Participate in the development of the local Integrated Neighbourhood Team and the delivery of services through integrated neighbourhood working An award has been made following direct award process A. The value of the contract will be based on registered patients. The service will be provided from 1 September 2025 to 31 August 2026. This is a new service with an existing provider.