1. Personalised Integrated Care
Jo Holmes
Head of Integrated Care
Age UK

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

6. 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

7. 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

8. 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

9. 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