Case Study 4: NHS Leeds West CCG – Improving Care to the over 75s by enhancing pro-active case management using primary care based Clinical Care Coordinators

In a nutshellThe BGS Fit for Frailty Part 2 describes the six essential characteristics of a good service for frailty. These are:

  • effective recognition, diagnosis and referral for frailty;
  • a person-centred ethos and practice;
  • integration of care in multiple settings;
  • expertise of staff;
  • practice underpinned by comprehensive geriatric assessment and care
  • planning
  • use of tools to assist case-finding.

Leeds West CCG has implemented the role of a Primary Care Clinical Care Coordinator in a Proactive Care Service which incorporates the above characteristics; the service is informed by the eFI and improvement methodology.


NHS Leeds West CCG used the Better Care Fund to enable GP practices employ Clinical Care Coordinators across all 37 practices within the CCG to enable pro-active case management. Each practice has an identified clinical care co-ordinator to deliver effective care and case management: the posts are hosted by the practices but the role has strong links with the Neighbourhood Teams and Community services.

SystmOne practices have used the electronic Frailty Index (eFI) to define their caseload A report was created to search SystmOne and identify all patients on the top 2% of the eFI list who were not known to the avoidable unplanned admission top 2% register (Leeds West CCG use the ACG System risk stratification tool to generate their core caseload). Practices using EMIS are identifying patients over the age of 80 years with the most multi-morbidity using the long term condition function within the ACG risk stratification tool before asking patients to complete the PRISMA 7 questionnaire to identify those with frailty. In light of the interdependencies with the existing ways of working in primary and community care, each Care Coordinator reviewed the unplanned admissions top 2% register to identify further patients likely to benefit from care coordination and/or could be taken off the unplanned admission register. The proximity of the Care Coordinators to the practice GPs and their links with the neighbourhood teams and community has allowed for established dialogue to ensure case identification and multidisciplinary decision making to provide the right care at the right time by the right professional for patients on their case list.

The Care Coordinators, with support from the Yorkshire & Humber Improvement Academy, are using the Model of Improvement to better understand the systems, processes and interventions which make care coordination operate in primary care. Additional improvement measures have been defined by the Care Coordinators and data will be collated at a practice level. The Care Coordinators will compare the results obtained for those on their case list with the results for all patients aged over 75 years on a weekly basis. In addition to this, the Care Coordinators will meet monthly as Community of Practice to share their learning, knowledge and to together explore the challenges and unknowns they encounter.

The overall aim of the programme is:

Outcomes being used to measure impact:

At CCG level:

Practice level data:

Outcome Measures (data will be presented per practice using run charts displaying results for a) all patients on care coordinator case load and b) all patients over 75 years of age to help demonstrate if care coordination is leading to a change)

Process Measures

The tacit knowledge and learning from each individual care coordinator is also captured via a care coordinator community of practice with virtual and face to face meetings to allow for idea sharing; individual learning logs, and learning from significant event analysis. 

Contact: Karen Newboult, Primary Care Locality Manager, NHS Leeds West CCG

Email: karen.Newboult@nhs.net