From care home to proactive care: Jan's story
How a pattern in Jan's primary care record triggered an MDT review and transformed her quality of life.
Setting
Care home resident
Trigger
High Brave Score
Outcome
100% better
How Jan was identified
Jan came up in an MDT review after Brave AI flagged her as a high-risk patient. The signal was clear in the data: a high volume of telephone contacts between her care home and the GP surgery, combined with a pattern of repeat medication requests. The frequency of these contacts indicated unmet clinical need that hadn't yet escalated to a crisis, but without intervention, likely would.
Jan's Brave Score marked her as a red candidate, meaning someone whose risk of an unplanned hospital admission was elevated enough to warrant immediate MDT attention.
The MDT response
Once identified, the team moved quickly. Three separate professionals were involved in Jan's care plan:
Pharmacist
Reviewed Jan's medication to address the pattern of repeat prescriptions and reduce polypharmacy risk.
Complex case practitioner
Conducted a general medical review, including follow-up on a history of chest infections.
Occupational therapist
Worked with Jan on practical strategies so she could manage her own health — ensuring she was "living and not just existing."
Critically, the team worked around Jan, not the other way around. Her voice shaped the care plan. As the occupational therapist described: "You became part of our team because we worked around you and your voice of what matters to you."
It's made me feel — as I say — 100% better. I can't praise it enough, because I know I would never have had this treatment if I was still being at home.Jan, North Sedgemoor PCN
What this case shows
Jan's case illustrates the core value of Brave AI: surfacing patients who are generating signals of unmet need in routine primary care data: high contact frequency, repeat medications, chest infections, but who might not otherwise be prioritised for proactive intervention.
Without the Brave Score to flag Jan for MDT review, her care would likely have continued reactively, each chest infection or medication query handled in isolation, with the underlying risks unaddressed. With it, a coordinated team was able to intervene early and deliver the kind of holistic, person-centred care that Jan describes as life-changing.