Personalised Integrated Care

Here's the shared example

Age UK’s Personalised Integrated Care programme brings together voluntary, health and care organisations in local areas to help older people who are living with long-term conditions and are at risk of recurring hospital admissions.

Age UK works with the organisations to co-design and co-produce an innovative combination of medical and non-medical support that draws out the goals the older person identifies as most important to them. Through the programme, Age UK staff and volunteers become members of primary care led multi-disciplinary teams, providing care and support in and through the local community.

The programme was initially launched in Cornwall in 2013, and in 2015 expanded to nine sites in total, each supporting 500 to 1000 older people over the course of one year.

At the heart of the Personalised Integrated Care programme lies a pathway that brings together local voluntary and health and care organisations to help put the older person in control of their health and enable them to regain their independence and quality of life.
• It uses risk stratification to identify a specific cohort of older people with multiple long-term conditions who are vulnerable to unplanned admission to hospital.
• Using a ‘guided conversation’, an Age UK Personal Independence Co-ordinator draws out the goals that the older person identifies as most important to them.
• Together, they create a care plan which brings together services from across the health, social care and voluntary sectors that are appropriate for the older person’s need. Effectively, the services ‘wrap around’ the older person, with the aim of reversing the cycle of dependency.
• Age UK volunteers can be assigned to help older people achieve their goals
• The care plan is reviewed regularly by multidisciplinary teams in a primary care setting.
• Clear safeguarding and escalation protocols are put in place to ensure that medical attention is delivered effectively and in a timely way when needed.

Population groups: 
Older people
People with long term conditions
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Age UK's Integrated Care Team
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