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: pam.creaven@ageuk.org.uk

Tel: 020 3033 1601