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Personalised integrated care

Integrated Care is a way of coordinating health and social care services to make sure they are based closely around people's needs. It is aimed particularly at those with complex and long-term health problems.


What is Personalised Integrated Care?

Age UK's Personalised Integrated Care Programme operates across England. We work to bring together voluntary organisations and health and care services in local areas. Together we provide an innovative combination of medical and non‑medical personalised support for older people living with multiple long‑term conditions who are at risk of unplanned hospital admissions.

Programme booklet

Find out how Integrated Care Services are bringing together leaders to transform services and outcomes for people living with long-term conditions.


How does the programme work?

Our Personalised Integrated Care programme brings together voluntary, health and care organisations in local areas to help older people who are living with long-term conditions and are at risk of recurring hospital admissions. We work with the organisations to co-design and co-produce an innovative combination of medical and non-medical support that draws out the goals the older person identifies as most important to them. Through the programme, Age UK staff and volunteers become members of primary care led multi-disciplinary teams, providing care and support in and through the local community.


Our pathway

At the heart of our Personalised Integrated Care programme lies a pathway that brings together local voluntary and health and care organisations to help put the older person in control of their health and enable them to regain their independence and quality of life.

  1. We use risk stratification to identify a specific cohort of older people with multiple long-term conditions who are vulnerable to unplanned admission to hospital.
  2. Using a 'guided conversation', an Age UK Personal Independence Co-ordinator draws out the goals that the older person identifies as most important to them.
  3. Together, they create a care plan which brings together services from across the health, social care and voluntary sectors that are appropriate for the older person's need. Effectively, the services 'wrap around' the older person, with the aim of reversing the cycle of dependency.
  4. Age UK volunteers can be assigned to help older people achieve their goals
  5. The care plan is reviewed regularly by multidisciplinary teams in a primary care setting.
  6. Clear safeguarding and escalation protocols are put in place to ensure that medical attention is delivered effectively and in a timely way when needed.

For me personally, I have been encouraged to look at patients where I thought their dependency levels would only increase and see that with a relatively small level of intervention, they can be encouraged back to a much lower level of dependency

Dr Tamsin Anderson | Newquay GP

Where is the programme running?

Phase one (2013) Cornwall
Phase two (2015) Portsmouth, North Tyneside, Ashford and Canterbury, East Lancashire, Blackburn with Darwen, Redbridge, Barking and Havering, Sheffield, Guildford and Waverley
Phase three (2017) South Gloucestershire, North Kent, South Kent, Croydon and Northamptonshire.

How can I find out more?

If you are interested in supporting us, or would like more information, contact us on integrated.care@ageuk.org.uk.

For more information:
Call Age UK on 0800 169 8787

Last updated: Oct 16 2017

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