Slide:1

Age UK Integrated Care

GP Education EventRoyal Surrey County HospitalThursday 28th May

Slide:2

Slide:3

Identified by GP Risk Stratification +

Older Person referred to Age UK Surrey

Older Person

Referral to I&A, (charged for) services, Voluntary Sector

1

PIC workers and Volunteers

1Age UK Personal Independence Coordinator

2Age UK

Volunteer

2

34

Guided Conversation Person centred support planPart of 500 Cohort

Age UK Volunteer

Age UK Personal Independence Coordinator

Multi Disciplinary Team Meeting

Slide:5

Community Support

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

Identity and status in the communityInvolvement in activities within the communityThe amount of choice and controlLoneliness and inclusion in Social groups

Slide:7

5 Co-design Workstreams1. Programme Governance and Information Governance2. 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

Slide:8

Example Smart Goals

Slide:9

www.knowledgebucket.org

Integrated.care@ageuk.org.uk

http://youtu.be/V5VsqSiHYVY