AnchorWell: Maintaining Health Stability - Proactive Care in Extra-Care Facilities: A Quality Improvement Initiative to Reduce Unplanned Healthcare Demand - Pilot

Introduction
 Urgent community interventions are disproportionately required by residents of independent or extra care living facilities, a small but high-need population. These settings attract individuals seeking more support than available in own homes; Whilst the need initially is often care related this is frequently driven by underlying medical conditions and the ageing process. Unlike nursing or care homes, extra-care living facilities lack enhanced primary care agreements, leaving rising needs unmet. With healthcare shifting from acute to community settings, addressing this gap is critical to improving quality of life and reducing unplanned demand on health services.

Aim
 Building on results from a previous proof-of-concept project (Coleman-Jones & Evans, 2024), we aimed to evaluate whether a proactive, structured model could be scaled to deliver affordable, preventative care for the extra care population.

Methods
 Residents from two extra-care living facilities were invited to participate in a 12-month project. Each received an initial Comprehensive Geriatric Assessment (CGA) followed by three-monthly reviews. Unplanned healthcare contacts (GP, community, ambulance, and hospital admissions) from the preceding year were compared with those during the intervention. Cost and frequency of contacts were analysed, supplemented by case studies for contextual insight.

Results
 Data collection continues until early 2026. Preliminary findings show marked reductions in unplanned service use and associated costs. Examples include one participant with 28 ambulance calls and 11 admissions pre-intervention, with none post-enrolment. Other cases highlight improved medication management, mental health stability, and identification of untreated conditions. Of 66 initial participants, 18 withdrew due to relocation or death. Feedback has been unanimously positive.

Discussion
 Early evidence suggests a proactive CGA-based model can reduce unplanned care and enhance health stability for residents in extra care facilities. This approach appears scalable and economically viable, offering significant benefits for individuals and the wider health economy.