Pam creaven int care session july 2014
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The document discusses Age UK's Integrated Care Programme, which aims to provide better and lower-cost care for older people. It outlines key barriers to integrated care in England, such as political and organizational challenges. Age UK's programme provides holistic care coordination led by volunteers to help reduce dependency and isolation. It serves as a critical friend to support service redesign and has shown success in locations like Cornwall. Important aspects of the program include data analysis, whole system working, personalization, and non-medical support to help older adults remain independent.
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Pam creaven int care session july 2014
- 1. Our Integrated Care Programme Pam Creaven Age UK - Services & Partnership Affairs Director
- 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
- 4. Age UK Integrated Care Pathway
- 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
Editor's Notes
- 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
- Horse boxing example – District nurse and commode