1. Slide:1 Age UK Integrated Care GP Education Event Royal Surrey County Hospital Thursday 28 th May

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4. Identified by GP Risk Stratification + Older Person referred to Age UK Surrey Older Person Referral to I&A, (charged for) services, Voluntary Sector 1 1 PIC workers and Volunteers 1 Age UK Personal Independence Coordinator 2 Age UK Volunteer 2 2 3 3 4 4 Guided Conversation Person centred support plan Part of 500 Cohort Age UK Volunteer Age UK Personal Independence Coordinator Multi Disciplinary Team Meeting

5. Slide:5 Community Support

6. Slide:6 Workforce Development Mission and values of Age UK Aims and objectives of Integrated Care Safe guarding and boundaries Guided conversations and role play Difficult conversations Evaluation and data protection Age UK and local services Our cohort and long term conditions Motivational techniques Person centred delivery and smart goals Signposting vs. referring I dentity and status in the community Involvement in activities within the community The amount of choice and control Loneliness and inclusion in Social groups

7. Slide:7 5 Co-design Workstreams 1.Programme Governance and Information Governance 2.Cohort Selection and Referral Age, LTCs, Hospital Admission, Cost, Cancer, EOL, Social Care Order and #/GP surgery 3.Care Pathways Best practise LTC care management including AUKS Clinical governance, red flags, roles and responsibilities 4.Workforce Development Recruitment timelines (plan, advertise, interview, train) PIC role and responsibility (MDT, GC, Volunteer match and supervision) Volunteers (support, evaluation) Training (Guided conversations, evaluation, local services, LTC, safeguarding, boundaries, difficult conversations, ) Training for MDT 5.Performance Financial model Nuffield evaluation Mental and physical wellbeing of cohort Staff satisfaction survey

8. Slide:8 Example Smart Goals

9. Slide:9 www.knowledgebucket.org Integrated.care@ageuk.org.uk http://youtu.be/V5VsqSiHYVY