Munisha Savania Targeted Prevention Manager (Older People) Too little too late Shared Problem Our current approach Aim: to systematically identify individuals (age 65 & over) at high risk of future social care need and provide advice, support and assistance to enable people to remain healthy, happy and independent for longer. Primary Care feasibility project - Applying learning Understand risks Identify cohort Identify individuals Conduct Check Offer support GP Practices (one per peer cluster) 1.Shanti Medical Centre (Dr Prasad) 2.Kearsly Medical Centre (Dr Wall and Partners) 3.Halliwell Surgery (Dr Hunt) 4.Dalefield Surgery (Dr Priest) 5.Little Lever Health Centre (Dr C Hallikeri & Dr S & M Parikh) 6.Pike View Medical centre (Dr Malhotra) Staying Well Check Tool Quality of Life Wheel Supported Conversation Examples of issues addressed Unsuitable accommodation Not able to manage house cleaning Memory problems No heating for two years Self medicating Not being able to manage Long term condition Broken teeth Getting in an out of the bath Potential Benefits More people able to maintain health and independence Reduced GP visits and hospital admissions More efficient targeting and use of resources Reduced or delayed need for intensive health and social care services, including residential/nursing home and costly crisis intervention Recognition and support for informal carers Potential developments Primary Care as focus for integration of health & social care? Earlier intervention increased savings potential Use of registers, high risk registers, best care concepts Holistic focus expanded use of Staying Well tool Informing service re-design & effective targeting of resources Monitoring & Evaluation How Staying Well is running -Client demographics and uptake rates -Client needs identified -Responsiveness of services -What Staying Well is achieving -Before and after score of the quality of life wheel measure improvements -Changes in key measures (e.g. better sleep, less isolated, able to get out and about after receiving the intervention -Case studies What Staying Well is costing/saving GM cost benefit analysis tool Costs identified from case studies Cost associated with delivering the Staying Well intervention Data on Identified Need Further Information Targeted Prevention Manager