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Our Integrated Care Programme
Pam Creaven
Age UK - Services & Partnership Affairs Director
Better care for older people at lower cost
Existing model of care
Future model of care
Key Barriers to Integrated Care in England
Contextual – demographic and financial pressures
Political – lack of political will; integrated care vs. choice/competition; no willingness to accept consequences (e.g. closing hospitals); constant organisational reform
Purchasing and Incentives – payment encourages acute/medical activity; payment by activities and by institution;; lack of innovation in contracting
Regulatory – episodic vs. whole-person; institutional vs. system; integration vs. competition; works against taking risks (e.g. health & social care)
Organisational – capacity; managing demand; bringing together primary-medical; health-social; other community assets (housing, education, welfare etc); governance
Functional – poor communication and networking; lack of ICT and use of new technologies to support people in the home (e.g. telehealth); lack of data and information
Professional – training; professional tribalism;
Service – resourcing better care co-ordination?
Personal – involving the public; shared decision-making; carers; community as asset
Leadership – New types of leadership
Knowledge – lack of learning from elsewhere in UK and abroad
Age UK Integrated Care Pathway
Our USPs
• Holistic care co-ordination led by voluntary sector and provided by trained volunteers
• Helping people to help themselves - reducing dependency
• Voluntary Sector key part of MDT – One care plan – clear escalation protocols
• Use of volunteers reduces isolation - volunteers can spot when health starts to decline/conditions exacerbate, as well as the barriers to good health outcomes
• ‘Guided conversations’ so older people are empowered and in control of their care plans. Wide range of areas covered.
• Flexible support services - including information, advice, benefits checks, all with focus on self-care and independence
• Bridge into other local Age UK services – e.g. handyperson, falls prevention, community transport, social activities etc
• Age UK Critical friend to support service redesign
Building on Success•Commenced Co-design phase with North Tyneside (FT, CCG and Council) + Cumbria, Portsmouth, Blackburn with Darwen
•Growing interest in the Age UK approach
•Cornwall won the 2013 HSJ award for Managing Long Term Conditions & Integrated Care Pioneer
•Cornwall service now being scaled up to 1000 patients
•Exploring new ways of contracting & financial solutions e.g. Alliance contracting, SiBs
•Independent evaluation by Nuffield Trust
•Testing new service models - sharing learning/knowledge transfer
Important aspects of Age UK’s Integrated Care Programme
• Starts with data and analysis – understanding what needs changing and why – develop a shared narrative & vision
• Whole system working towards same outcomes – reducing unnecessary admissions to hospital, improving quality of life, quantification of cashable savings
• Targeting – segmentation
• Cost benefit analysis – with robust performance management
• Person-centred – personalised around what matters most to the individual
• Non-medical model – includes new role to co-ordinate and support older people to remain as independent as possible, for as long as possible
• Continuity of care
• Reducing isolation and loneliness
• Influencing/changing professional practice – embracing new ways of working
Pam Creaven
Age UK - Services & Partnership Affairs Director
Email: [email protected]
Tel: 020 3033 1601