Making integrated care areality for older peoplePam Creaven – Age UK, Director of Services
Older people and health• Older people represent 60% of all hospital admissions – olderpeople are often going into hospital ‘in crisis’• There are 14m people aged 60yrs or more; it is estimated there willbe over 50% increase of older people in the next 25 years.• Most older people tell us they want to live independently andhealthily at home for as long as possible, and have choice andcontrol over the services they need.
We know that prevention and earlyintervention works.Some of the key questions:How do we divert money from acute hospital services to fundpreventative services when the health system has been predominantlyorganised to respond to crisis?How do we transform services for older people that deliver betteroutcomes and are cost effective?How do we ensure that services are person centred, designed aroundwhat a person wants and needs?
What are we doing to improve services for olderpeople?We are developing an evidence-based model for preventative services andcommunity-led integrated care pathways that:• reduce unnecessary hospital admissions over time• cost less overall than acute services• improve the wellbeing and quality of life of older people living with longterm conditions• enables older people to regain control of their lives
What unique about Age UK’sintegrated care programme?• Helping the person – not the condition - person-centred careintegrating across multiple long term conditions as well as ancillarypreventative services that make a huge difference• A seamless way of connecting health and care services –creating new care pathways that are clinically endorsed, that workfor older people and ‘bridge the gap’• Major step change in the approach – putting the local Age UK atthe centre of older people’s health outcomes – requires a ‘wholesystem change’• Targeted approach using the risk stratification of patients and asound evidence base to ensure services are focussed where theycan have the greatest impact
Whole system changeJoint working & co-ordination across avast range of external stakeholders
Investing to SaveAge UK is looking to attract socialinvestment and capitalise on ourlocal presence and our collectiveaccess to supporters and volunteers•Finance from publicsector•Finance from ethicalinvestors•Finance from charitablesectorCreating a sum forinvestment in services•New services for olderpeople delivered by localAge UK to reduce hospitaladmissions•Reshaping health andcare services to generatecashable savings•Project commissionedand performancemanaged by CCG and AgeUKA programme ofaction•Commitment to pay bypublic sector onachieving resultscompared to an agreedpredicted baseline•Benchmarked againstbaseline of trajectories•Financial return toinvestor, surplus forpublic sector andpartnersA commitment torepay the investor
Why Age UK?• One of the UK’s major charities with a strong and trusted Brand andmany thousands of supporters and volunteers• The only major charity focused solely on improving later life• Works with and through a network of local Age UKs that are highlyvalued and respected in their communities• National credibility and extensive local reach is a specialcombination• Ability to bring different organisations, professions and key playerstogether to help transform the system and better help older people
Age UK Cornwall Pathfinder Project• 100 older patients with two or more long term conditions identified in twoGPs surgeries using historical data, risk prediction & case management• Patients have the potential of being supported in the community andwant to change their current behaviours and lifestyle• Two Personal Independence Co-ordinators and team of volunteersrecruited by Age UK Cornwall to provide support to the patients• The team works towards best practice care management and createsescalation plans, all agreed by the local health service• Age UK Cornwall service includes anticipatory planning, self care, peersupport and motivational interviewing• Focus is on improving patient’s health and wellbeing outcomes andreducing NHS costs
Clinical integration at ground level‘This has opened up a whole newopportunity for new ways of working withinthe NHS… as a health team we havebenefited from the involvement of thevolunteers…. This has been educationalwhere I thought patients dependencywould naturally increase… with a little inputwe have seen dependency decrease’Dr Anderson Newquay‘… This service helps people tomanage their own conditions in theirown home and prevents hospitaladmissions…. We are getting newideas, learning and developing asdistrict nurses’Lucy Clement – District NurseTeam LeaderAge UK Cornwall Pathfinder Project
Cornwall Pathfinder - Initial Findings• 30% reduction in AcuteAdmissions• Over 16% improvement inpeople’s wellbeing• £4.40 saved for each £1invested• Integrated Team working well,and changing practice outsidethe initial 100 patientsNext Steps• Independent evaluation withNuffield Trust• Build a business case to expandthe service to 1,000-2,500patients• Identify funding for the service• Develop the service operationfor when patient numbers areincreased