Age UK partnership

 Age uk.jpgWe are delighted to be working in partnership with Age UK to support the spread and adoption of the Integrated Care Model across Kent, Surrey and Sussex.  

We aim to bring together CCGs, Local Authorities, Voluntary sector, providers and Social Care to support older people living with long term conditions. We intend to provide personalised, integrated care and support which uses an earlier intervention and  prevention strategy.

The issue:
Lonely and isolated older people who have multiple long term health conditions are at greater risk of ill health and unplanned hospital admissions.

Our aim: 
KSS AHSN and Age UK are going to work together in partnership to address earlier intervention and prevention in health issues of older people by providing personalised, integrated care and support. This is an innovative project run by Age UK Surrey, which is tackling the source of the problem with an integrated service that promotes independence and builds confidence and wellbeing.

The project

 "Living Well in Guildford and Waverley" was set up in August 2015 and is a partnership with Guildford and Waverley Clinical Commissioning Group and the national Age UK team. There are currently 9 pilot sites running across England, 2 of which are in KSS: Guildford & Waverley and Ashford & Canterbury.

A similar project with an integrated care approach was trialled in Cornwall to help address the issue of avoidable hospital admissions. It showed that by addressing older people's personal and emotional needs - such as loneliness, lack of confidence and isolation - unplanned hospital admissions could be dramatically reduced.

The Multi-Disciplinary Care Team Model represents a new way of working, featuring non-medical support delivered by multi-disciplinary teams that include the third sector.  Volunteers are a key aspect of delivery in this project.

An integrated care pathway is at the heart of the programme with an approach as follows:

  • Uses predictive risk stratification to identify older people most likely to be admitted to hospital with 2 long term conditions.
  • Uses a multi-disciplinary approach through MDT meetings including health and social care partners in a primary care setting.
  • Uses a "guided conversation" an Age UK Personal Independence Co-ordinator works with older person to draw out their goals.
  • Uses volunteers to support older people to achieve their goals

For more information, contact Lisa James, Senior Programme Manager lisa.james@nhs.net