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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.

WHO Global Consultation on Integrated Care for Older People

We participated and presented a poster at the WHO Global Consulation in Berlin, October 2017. The poster highlights some of the problems, challenges and outcomes of the programme to date. Our model of Personalised Integrated Care formed part of the discussions at this three-day event.


Blended evaluation of Phase 2

The blended evaluation of Phase 2 of the Personalised Integrated Care programme draws on evaluative evidence and performance-management data collected locally and nationally up until September 2017. 

Key findings from the evaluation:

Involvement in the programme has had a positive and lasting impact on the wellbeing of the older people by:

  • helping older people become aware of their own needs, and regain a sense of control and purpose in their lives
  • enabling independence through practical support
  • reducing isolation and raising ambition by motivating and supporting older people to re-engage with interests and become more socially connected
  • providing an ‘extra arm’ of support for older people that remains after their involvement in the programme ends.

Although not quantified, the support provided by the Personal Independence Coordinators (PICs) has released time from primary care. It has improved the quality and coordination of care, as well as facilitating timely access to care. It has also helped to shift conversations away from a purely medical model of care.

More generally, Phase 2 of the programme has generated transferable insights about how the model works on the ground, including:

  • lessons learned about risk stratification
  • creating demand
  • multidisciplinary team working involving the voluntary and community sector
  • involving volunteers
  • connecting people to community assets
  • the time required to stabilise the delivery of new interventions.

The learning about delivery of the model and its impact will be of value to other health and care systems as they develop and implement holistic and personalised preventive care models involving the voluntary and community sector.

Evaluation reports

Read the key findings of our evaluation of Phase 2 of the Personalised Integrated Care programme.


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.

We're here to help

We offer support through our free advice line on 0800 055 6112. Lines are open 8am-7pm, 365 days a year. We also have specialist advisers at over 140 local Age UKs.

 

Last updated: Aug 06 2018

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