2. Better care for older people at lower cost
Existing model of care
Future model of care
3. 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
5. 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
6. 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
7. 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
8. Pam Creaven
Age UK - Services & Partnership Affairs Director
Email: pam.creaven@ageuk.org.uk
Tel: 020 3033 1601
Notes de l'éditeur
The Age UK Int Care programme started with the Cornwall Pathfinder (here from Joy later)
Cornwall was the first site to test
Plug booklet
This is what we are trying to evidence can happen
60% of all hospital admissions are older people
14m people aged 60yrs or more
50% projected increase of older people in 25 years
People with Dementia occupy a quarter of hospital beds & often have delayed discharges
Scope for improvement in many areas & reduce inequalities in treatment
Older people want to live independently and healthily at home for as long as possible, and have choice and control over the services they need
We know from our experience that these are some of the barriers that require overcoming to have effective integration.
Distributed leadership – mobilising leadership at all levels
Essentially we are adapting this care pathway in 3 to 5 other areas across the UK.
The aim being to have a robust evidence base of what works – the programme will be evaluated by the Nuffield Trust. Bottom up build – important factor of success
Targeting a group of patients who can be supported on the ground to manage their conditions more effectively.
Targeting people at high risk of going into hospital and with co-morbidities – using a recognised risk modelling tool.
Co-morbidities e.g. CHD, Angina, COPD, diabetes, dementia, stroke, UTI - with focus on those older people amenable to change. Wellbeing reviewed as part of guided conversation.
Helping the person not just the condition – co-ordinated, holistic care pathways that makes best use of all services.
Creating a flexible funding model: Services could be funded by a SIB or, in some areas, by the NHS.
Targeting a group of patients who can be supported on the ground to manage their conditions more effectively.
Targeting people at high risk of going into hospital and with co-morbidities – also high cost with evidence that admissions can be avoided – using a recognised risk modelling tool & international evidence base .
Co-morbidities e.g. CHD, Angina, COPD, diabetes, dementia, stroke, UTI - with focus on those older people amenable to change. Wellbeing reviewed as part of guided conversation.
Helping the person not just the condition – co-ordinated, holistic care pathways that makes best use of all services.
Creating a flexible funding model: Services could be funded by a SIB as local resource shrinks and modelling improves
Creating new contractual framework (alliance contracting?) – aligning incentives across the system (3 things reduce admissions, improve QofL & cashable savings) – develop gain share approach – away from episodes/activity to outcomes as determined by the older person
Our USPs – Age UK as critical friend – expert practitioners of WSC
Holistic care co-ordination led by voluntary sector and provided by volunteers – bundled, flexible service offer
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 – 1 care plan within a MDT
Flexible support services - including navigation and signposting with focus on self-care and independence
