HSUG / LGA Housing and Health Workshop Age UK Integrated Care Monday 28th September  

Age UK Integrated Care 1 2 4 3 Identified by GP Guided Conversation Older Person referred to Local Age UK Older Person Age UK Personal Independence Coordinator Referral to I&A, (charged for) services, Voluntary Sector 1 2 Part of 500 Cohort Guided Conversation Person centred support plan Age UK Personal Independence Coordinator Age UK Volunteer 1:1 Support 4 3

Identifying target groups Older people: Older 2 or more long term conditions Make a difference Benefit from community support Reducing Cost: Risk stratification for unplanned hospital admissions Reducing social care costs   Aspirational 1:4 savings , help double run and then restructure from emergency to prevention, run out of volunteers

Impact of the Intervention   Improved Wellbeing for older people: Person centred smart goals Emotional wellbeing Physical wellbeing Reducing Cost: Reducing cost across the whole system Performance Management Framework Financial Model Whole System Change: Multi disciplinary team working Shared single care plan Loneliness and isolation

Evaluation Challenges Information Governance and Data sharing Honorary contracts, co-located, NHS emails NHS Toolkit Local IG procedures and consent letters, phone calls and records Skills for care video on information governance (https://vimeo.com/127479930)   Attribution Local Cornwall evaluations Nuffield evaluation across all the sites (not being a halth organisation) matched control group (not RCT) and Cornwall did a local one

Results to Date 20% www.knowledgebucket.org http://www.ageuk.org.uk/professional-resources-home/services-and-practice/integrated-care/integrated-care-model/ 20%