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Theory to Practice – Integrated Care with the Voluntary Sector – Best Practice Pam Theory to Practice – Integrated Care with the Voluntary Sector – Best Practice Pam Creaven Age UK - Services & Partnership Affairs Director

Older People and Health • 60% of all hospital admissions are older people • Older People and Health • 60% of all hospital admissions are older people • 14 m people aged 60 yrs 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.

Key Barriers to Integrated Care in England Contextual – demographic and financial pressures Political 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; healthsocial; 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 – how do we best provide 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

Age UK’s integrated care programme • Targeting a group of patients who can be Age UK’s integrated care programme • 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 comorbidities – 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.

Evidence Base • International best practice – evidence review • Geisinger (USA) - 44% Evidence Base • International best practice – evidence review • Geisinger (USA) - 44% reductions in 30 day readmission rates by adopting best-practice pathways • VA (USA) integrated care model - 50% reduction in bed days for patients with multiple chronic illnesses • Kaiser Permanante (USA) - lower admission rates for a no. of conditions e. g. asthma, bronchitis, angina. NHS 4 -5 times higher than Kaiser

Better care for older people at lower cost Existing model of care Future model Better care for older people at lower cost Existing model of care Future model of care

Whole System Change – The Complexity of the Challenge System Integration Organisational Integration Functional Whole System Change – The Complexity of the Challenge System Integration Organisational Integration Functional Integration Professional Integration Service Integration

Age UK Integrated Care Pathway Age UK Integrated Care Pathway

Newquay – The People Newquay – The People

Introducing Betty Diabetes Low mood – afternoons/weekends Hypertension Embarrassment – “state” of her home Introducing Betty Diabetes Low mood – afternoons/weekends Hypertension Embarrassment – “state” of her home Stroke Urinary Tract Infection Respiratory issues Social network - will not invite people around, worried about falling outside Fear – doesn’t want to leave her home Lack of confidence – doesn’t like the way she looks anymore Dependency – nurses/social care/GP is her network

Dependency Cycle Regular GP Visits Increasing Acute Admission District Nurse 3/week Community Matron Increasing Dependency Cycle Regular GP Visits Increasing Acute Admission District Nurse 3/week Community Matron Increasing Isolation and dependency Increasing Primary Carers 3/day Regular unplanned hospital admissions Watching TV 8+ hours/day Increasing Social Care Increasing Clinical Community Care

What We Do Guided conversation, motivation, goal setting ü ü To get to know What We Do Guided conversation, motivation, goal setting ü ü To get to know more people To get out of her home To buy her own food To get the building work done ü To do something for her Part of clinical and social care meetings; shared management plans and outcomes Requested pharmacy check Telehealth Find list of builders & help put together a schedule Exercise buddy Coffee mornings, lunch clubs, shopping trips, counselling sessions, peer befriending, benefits, carer support, transport

Age UK Cornwall Pathfinder Project Clinical integration on the ground ‘This has opened up Age UK Cornwall Pathfinder Project Clinical integration on the ground ‘This has opened up a whole new opportunity for new ways of working within the NHS… as a health team we have benefited from the involvement of the volunteers…. This has been educational where I thought patients dependency would naturally increase… with a little input we have seen dependency decrease’ Dr Tamsin Anderson– Newquay GP ‘This service helps people to manage their own conditions in their own home and prevents hospital admissions…. We are getting new ideas, learning and developing as district nurses’ Lucy Clement – District Nurse Team Leader

Cornwall Pathfinder - Initial Findings 40% reduction in unnecessary acute admissions 23% improvement in Cornwall Pathfinder - Initial Findings 40% reduction in unnecessary acute admissions 23% improvement in people’s wellbeing £ 4. 40 saved for each £ 1 invested 5% reduction in social care costs 87% said work more meaningful Plus: Important changes to practice, plus halo effect reported - Around 10% of patients go on to be community networkers/volunteering to support others

Our USPs • Holistic care co-ordination led by voluntary sector and provided by trained 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

Building on Success • Cornwall won the 2013 HSJ award for Managing Long Term Building on Success • Cornwall won the 2013 HSJ award for Managing Long Term Conditions & Integrated Care Pioneer • Cornwall service now being scaled up to 1000 patients • Work taking place on new contractual framework e. g. Alliance contracting • Commenced Co-design phase with North Tyneside (FT, CCG and Council) + Cumbria, Portsmouth, Blackburn with Darwen • Growing interest locally • Independent evaluation by Nuffield Trust • Testing new service models - sharing learning/knowledge transfer

Early Intervention – Social Prescribing Early Intervention – Social Prescribing

Important aspects of Age UK pilots • Starts with data and analysis – understanding Important aspects of Age UK pilots • 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

Voluntary Sector – Best Practice Pam Creaven Age UK - Services & Partnership Affairs Voluntary Sector – Best Practice Pam Creaven Age UK - Services & Partnership Affairs Director Email: pam. [email protected] org. uk Tel: 020 3033 1601