Personalised Integrated Care Jo Holmes Head of Integrated Care Age UK

Strategic Context Maximising Healthy ‘Ageing’ Five year forward view New models of care Personalised health and social care / budgets Scale and pace

Challenges (1) System wide – active collaboration Different approaches to collaboration Different levels actively involved in collaboration Different approaches to co- design Performance management : moving from pathways to person centred approach Use of data to select cohort ‘live’ performance management Moving towards segmented populations/impact of person centred approach

Challenges (2) Moving from outputs to outcomes Understanding how multiple providers all shape outcomes What resources, human and financial are required to achieve a set of personal outcomes Supporting older people to define what they want to achieve/ the art of the possible MDT working – optimising the medical and non-medical model Different levels of engagement and participation from MDT professionals Moving from ‘referrals’ to case management

Strategic partnership development AHSN – KSS – Support across the system Scale, spread and Pace Vanguard support Early development support Through Secondment Strategic alignment Active shared learning

Next steps Outcomes from programme learning Financial modelling, outcomes Scale and spread and building on the model – Scale up in larger geographical area – Financial solutions – i.e. Frailty as a LTC, PHSCB, – End of life/advance care planning