Anticipatory Care services for GPs

HomeLink Healthcare’s Anticipatory Care model is a forward-looking, patient-centred approach that helps individuals—especially those with long-term or complex conditions—stay well and avoid using GPs’ valuable time with unnecessary appointments.

By identifying risks early, developing personalised care plans, and coordinating multidisciplinary support, we help empower patients, and ease pressure on general practice.

We work in partnership with GPs and Primary Care Networks (PCNs) to identify early signs of deterioration in rising risk patients.

Regulated by the CQC, we are specialists in delivering nursing and therapeutic care at home, with a team of highly-skilled and experienced clinicians dedicated to proactive support, every day of the year.

Our anticipatory care services promote well-being and self management and are built around compassion, innovation, and partnership—with the aim of keeping people well, independent, and at home.

Delivering Anticipatory Care in partnership with GPs: How it works

We partner and collaborate with GP practices to work as an extension of the team—offering assessments, care planning, and ongoing support for patients with long-term conditions, frailty, or recent hospital discharges.

1. Use risk stratification data to identify patients who may benefit from anticipatory care in the home e.g. those with complex needs, frequent attenders, or recent discharges. Anticipatory care can be provided to cohorts of patients that are either:

– identified as potential future high service users

– current high service users that would benefit from targeted prevention and support

– patients that have fallen into secondary care crisis and need additional support.

In line with current health care policy direction, this addresses the three priorities of prevention, digitalisation and activity shifting from hospital-based care to community-based, patient-centred, holistic care.

2. Conduct a holistic assessment considering medical, psychological, and social factors.

3. Co-develop a tailored anticipatory care plan (ACP), aligned with the patient’s goals and shared with all relevant professionals.

4. Provides proactive follow-up, coordination, and self-management support, ensuring the necessary ongoing care.

5. We provide regular reviews and feedback and adjust care plans collaboratively as patient needs evolve.

Why GPs partner with HomeLink Healthcare

✅ Free up GP time

We take on elements of care planning, home assessments, and patient education—freeing up time for GPs to focus on complex or urgent cases.

✅ Provide patients with more personalised support

Our clinicians spend more time in patients’ homes, allowing for in-depth assessments and meaningful relationship-building, therefore increasing patient satisfaction on behalf of the practice.

✅ Seamless care planning and feedback

We provide detailed, up-to-date care plans and clinical feedback via shared electronic systems—ensuring you’re always informed about your patient’s care journey.

✅ Extend the practice’s multidisciplinary team

Our nurses, physiotherapists, reablement and healthcare support workers act as an extension of your practice, offering care continuity and specialist expertise in the community.

✅ Support the most vulnerable

We focus on patients with frailty, multiple long-term conditions, or recent hospital discharges—those most at risk and often hardest to reach with traditional care models.