Population health management

Short Title Proactive Population Health Management
Category Living with frailty (mild / moderate)
Organisation Dorset Healthcare University Foundation NHS Trust
Contact Name Emma Gardner Community ANP tel. 01747 475253
Contact Email emma.gardner3@nhs.net
Web Link
Sector Community
Region Dorset
Postcode SP7 8BD
Active Yes


What matters most to the patient

Devising individualized, patient led management plans addressing the management health care conditions through social prescribing to achieve their stated goal.
Caseload finding through GP note finding screening those with moderate frailty score, long term conditions (HF, high BP, diabetes, COPD, CKD) codes. 39 patients identified, nursing homes and severe cognitive impairment not approached, 3 declined, 10 patients visited.


To delay a decline in frailty, hospital admission avoidance, reduce patient GP + OOH contacts. Details and case studies to follow.

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