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Feb. 14, 2016

Personalised Integrated Care Programme

Region: Europe Implementation report Empowering and engaging people and communities, Reorienting the model of care, Coordinating services within and across sectors Source: Age UK

All too often older people living with long-term conditions do not have a sustainable care plan to keep them out of the hospital. Launched in Cornwall in 2013, Age UK’s Personalised Integrated Care programme uses risk stratification to both identify those older people who are at risk of recurring hospital admissions and provide a combination of medical and non-medical support. This support starts with a 'guided conversation' between the older person and an Age UK Personal Independence Co-ordinator. In this conversation they outline the goals that the older person identifies as most important to him or her and they draw a care plan which will include a combination of voluntary, health and care organisations. Following this, an Age UK volunteer is matched with the older person, both to help in achieving his or her goals, but also to encourage them to be more independent in managing their own care. As part of this programme, Age UK staff and volunteers become members of a primary care led multi-disciplinary team, which reviews the care plan regularly. Interim results from the programme indicate there has been a 26% reduction in non-elective hospital admissions. Moreover, 20% of those supported later become volunteers themselves. In addition to these metrics, the Age UK website highlights the benefits of the programme via a video about a hypothetical older person named Reg, and several case studies are presented in the programme's booklet. Last year, the programme expanded beyond Cornwall to nine different sites in the UK.