This was the first project focusing on older people as one of eight discrete population groups within the practice, aligning with a value-based healthcare approach in primary care. Built on the principles of learning systems thinking and a data-driven approach, the project ensures that care for older adults is proactive, equitable, and continuously improving.
Our fit-for-purpose model of care addresses the unique needs of older people, emphasizing preventive and anticipatory management rather than reactive interventions. Starting with multidisciplinary team tailored for this population provides holistic care, spanning medical, social, rehabilitative, and supportive services. We actively consider equity, ensuring that vulnerable and underserved groups receive the care they need. The multi-disciplinary team evolved into an integrated practice unit over time as ways of working became embedded into the culture.
A blended model of face-to-face and home-based care maximises accessibility and patient preference. Where appropriate, we incorporate purposeful technology, including tele-examinations, remote monitoring, and AI-driven clinical decision support, to enhance care delivery, minimize hospital visits, and provide real-time interventions.
Underpinning our model is a learning health system, where data, patient feedback, and outcome tracking drive continuous improvement. Using the ICHOM Older People dataset, we measure what truly matters—not just clinical outcomes but patient-centered metrics like independence, mobility, well-being, and quality of life.
By integrating value-based care into primary care for older adults, this project delivers high-impact, personalised, and future-focused care, ensuring that older people receive the right care, at the right time, in the right place.
