Age UK is pioneering a new way of working with health and social care partners to support the wellbeing of older people whilst at the same time improving people’s experience of care and reducing the cost to health and social care.
The model is being tested across the country in 9 areas.
We work together with GPs and other primary care workers to produce a list of people in their area who have long term health conditions and who have had emergency admissions to hospital in the last year.
The doctor then contacts the people, explains about the programme and asks if they would like to take part
The next bit is where the magic begins:
The Age UK worker receives the referral from the GP and arranges to visit the person. They start with a conversation – not an assessment – just a normal chat between two equals.
The person has the time to talk about their life, how they feel, what is important to them, any problems they are having. They will often be people for whom life has become a cycle of hospital visits, doctors’ appointments and carers coming in and out during the week, with no social life or interest.
Together they come up with a plan to achieve something that would make their life better – it could be anything from being able to go out to the shops or social club to going fly fishing! The local Age UK knows about all the opportunities that are available in the local area.
The Age UK worker takes the plan back to the person’s GP where a team of health and care workers discuss it and see how they can play a part in making it happen. Will they need transport; could their medication or nurses visits be changed to give them more time to do what they want to do?
A volunteer is introduced to the person who will be there for them, every step of the way, motivating them and giving them the encouragement to achieve their goal, reconnect with their friends and community, basically get their life back.
And it works! In Cornwall where the model was first tested, early evaluation using a matched cohort of 325 people which has demonstrated that emergency department attendances have reduced by nearly a third, emergency hospital admissions have reduced by 37.4%, and there is a net saving of £1,500 per person per year across the whole system. Our ‘quiet revolution’ is slowly turning the tide – saving money, changing behavior, and changing lives.