Age UK’s Personalised Integrated Care Programme: where are we now?


Integrated care is one of the most important concepts in healthcare today.

For those unfamiliar, integrated care is a way of coordinating bodies from across health and social care to deliver truly personalised care for individuals. It moves the system away from an ‘episodic,’ fragmented care model to one that’s more continuous and seamless.

At Age UK, our Personalised Integrated Care Programme continues to expand and our interim evaluation results show it going from strength to strength.

What is our Personalised Integrated Care Programme about?

Our programme sees Age UK staff working with trained volunteers, doctors, nurses, social workers and others to provide wraparound care for older people with long-term conditions who regularly experience unplanned admissions into hospital. This care is tailored to goals the older person identifies as most important to them. Frontline practitioners involved have said that they feel empowered from making a difference.

For me personally, I have been encouraged to look at patients where I thought their dependency levels would only increase and see that with a relatively small level of intervention, they can be encouraged back to a much lower level of dependency.

Dr Tamsin Anderson | Newquay GP

We launched the programme because we saw that older people were not getting the personalised support they needed to live full lives at home and were instead in and out of hospital. Statistics show older people representing over 55 percent of all hospital admissions and, on average, people over 75 spending five and a half days longer in hospital than those between 15 and 59.

Our aims are to improve the health and wellbeing of older people by tailoring services to meet their needs, improve the experience and quality of care they receive, and reduce unplanned hospital admissions amongst older people with multiple long-term conditions. Ultimately, we want to deliver transformation to the whole health and care system.

The programme first launched in Cornwall in 2012, and last year was particularly momentous for us.

Achievements in 2015

Evaluations from our programme in Cornwall, released last year, were very promising.

They showed a 31% reduction in all hospital admissions, a 26% reduction in emergency ones, and a 20% improvement in older people’s health and wellbeing, proving our programme is providing great benefits for older people whilst reducing pressure on the system.

What’s more, we believe there is enthusiasm for the programme, with a fifth of older people supported going on to become volunteers themselves.

However, statistics can’t tell the full picture. We have heard first-hand from older people about how it’s helping. ‘Gina,’ who has angina, dementia and had regular falls, told us how she longed to take her dog for a walk but was worried after being housebound for so long. The team in Cornwall arranged for her to have balance training and gradually her mobility improved. Now, she can both take her dog for a walk and throw a ball for him, something which she previously thought impossible.

Activities like walking a dog may seem simple, but it can be challenging for those with multiple long term conditions. To be able to do something like this again can make a real difference to people’s lives and reconnect them with their communities.

This progress gave us a great boost as we carried out another big feat in 2015: expanding the Programme to nine sites in total across the UK, each supporting 500 to 1000 older people over the course of a year. Cities from Portsmouth to Sheffield are now getting a service we believe is truly transformative.

Increasing the scope of our programme will not only give us the opportunity to test it at a greater scale but, most critically, allow us to transform the lives of more older people with long-term conditions.

Need is growing all the time

We know the need for integrated care is growing all the time. Life expectancy continues to increase, and by 2020 the ONS estimates 7 million people in England aged 60 or over are likely to have two or more long-term conditions.

With this in mind, we hope our Personalised Integrated Care Programme will continue to develop and provide care and support to enable older people like Gina live more fulfilling and independent lives.

Read more about our Integrated Care Programme and download our new Integrated Care Services booklet

Author: Age UK

Age UK is dedicated to helping everyone make the most of later life. In the UK we help more than 7 million older people each year by providing advice, combating loneliness and enabling independence. Locally, we work as part of a network of independent charities which includes Age UK, Age Cymru, Age NI and Age Scotland and over 150 local Age UK partners in England and Wales.

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