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Care Co-ordinators: better care through transition
Mary Bradley Chief Executive, Age UK West Cumbria
• Why is care co-ordination important?
• What are the benefits and to whom?
• How can it be achieved?
• Can this be evidenced?
• The way forward
Why is Care Co-ordination important?
Long Term Health Conditions
• 69% of total health & social care spend in England (DM 2008) • 2025 – 18 million people will have LTC • Depression:- 25% of older people living in the community
have symptoms which warrant intervention. (85% of people over 65 do not receive any NHS support) • Dementia:- 1 person in 6 over 80 1 person in 3 over 95 now = 820,000 people in UK
Multimorbidity
% Dependent
Disability, Age and Activities of Daily Living
In eight years’ time, demographic change alone would mean that there would be:
• Nearly 2.7 million people aged 75+ with at least one limiting long term illness and over 4.3 million people aged 65+ with LLTI
• People living an average of 7-9 years at the end of their lives with a disability
• Nearly seven million older people who cannot walk up one flight of stairs without resting
• One-and-a-half million older people who cannot see well enough to recognise a friend across a road
• Over 4 million with major hearing problems • Up to a third of a million people aged 75+ with dual sensory loss • A third of a million who have difficulty bathing • Nearly a million with dementia • Between 4-7 million with urinary incontinence • One-and-a-half million suffering from depression
Typical Pathway
Awareness - Information - Diagnosis - Information - “treatment” Life adjustments - living well with - acute episodes - ageing and condition impact - carer support - palliative care - afterwards
What are the benefits and to whom?
Main stakeholder benefits Who? How? Measured?
People Health and well being Living well in later life Helping each other ‘Future proofing’ the community
Long term, whole population. Short term, each individual makes a difference
Third Sector More effective, more satisfaction, more volunteering
People helped, timeliness of intervention
NHS (health economy)
More cost effective Prevent hospital admissions, more care at home
Recognise difference between each stakeholder’s evaluation ‘on their own terms’ and the overall community benefit.
A Whole System Approach
Working together to use the resources available to the maximum effect Step changes towards:- • More self care and information • Valuing of prevention • Tackling health in equalities • Delivery of care outside of acute hospitals • Empowerment of patients • Engaging citizens
What People Tell Us
• Being active, staying healthy and contributing
• Continuing to learn
• Friends and community – being valued and belonging
• The importance of family and relationships
• Valuing diversity
• Approachable local services
• Having choices, taking risks
How can care co-ordination be achieved?
Social Prescribing
Telephone and/or Visit Establish need / want and further information, create Age UK paperwork and input on Charity Log
Stage 1
Stage 2
Referral to Age UK Worker If more complex case that requires action.
Referral to other third sector organisation / Agency Alzheimer's, Cruise, West Cumbria Carers, University of the Third Age
Referral to other Age UK Service: MoneyWise, Handyperson, Help at Home, Fit as a Fiddle, social groups and community activities
Referral for Volunteering Opportunities for volunteering with Age UK projects / services, other organisations services or local community projects looking for volunteers. Important to utilise people’s skills as assets in the community.
GPs Health Professionals Other
Health
Third sector post as referral/signposting hub Bridges gap between health, third sector and assets in the community
Underlying philosophies
• Asset Based Community Development • Co-Production and Co-Design (informing
future commissioning of services) • Partnership between Third Sector and
NHS • Can do
One number
Knowledge of Materials and community Information Hub Information Independent Living Volunteers Events Signposting Targeted information Services Activities
• Can be accessed electronically on GP computers
• Referral is emailed to practice manager or reception staff
• Centre for the Third Age Coordinator collects forms from reception on a daily basis
Referral form
Can this be evidenced?
Using 5 ways as a Framework
• Connect - with others, at home, at work, in your community • Be Active – an active lifestyle not only keeps our bodies healthy, but
makes us feel good as well • Keep Learning – trying something new can help keep our minds and
our lives active • Give – giving to others makes us feel better, and 2010 could not
have happened without the generosity of the people of Liverpool • Take Notice – It’s easy to rush through our busy lives without
pausing for thought
Star Outcomes
• Picture • Focus on person’s issue
• Deal with complexity • Encourages self management • Measure progress
Target Wellbeing
1%
12%
38% 31%
18%
Pre TWB None of the time
Rarely
Some of the time
Often
1%
2%
7%
66%
24%
Post TWB None of the time
Rarely
Some of the time
Often
I have been joining in social activities’
‘There are social activities available to me’
5%
9%
43% 28%
15%
Pre TWB None of the time
Rarely
Some of the time
Often
1% 2%
27%
53%
17%
Post TWB None of the time
Rarely
Some of the time
Often
‘I have good relationships with others’
0% 1%
16%
57%
26%
Pre TWB None of the time
Rarely
Some of the time
0% 1%
15%
63%
21%
Post TWB None of the time
Rarely
Some of the time
Often
All of the time
Moneywise
40.00
45.00
50.00
55.00
60.00
65.00
70.00
75.00
80.00
85.00
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Female claimants vs claimant age range
Claimants Aged 80 and Over Claimants Aged 70-79 Claimants Aged 60-69 Female
Moneywise (cont)
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All
Sain
ts
Asp
atri
a
Bolto
ns
Brou
ghto
n St
Bri
dget
's
Chri
stch
urch
Clift
on
Crum
moc
k
Dal
ton
Der
wen
t Val
ley
Elle
n
Elle
nbor
ough
Ewan
rigg
Flim
by
Har
ring
ton
Hol
me
Kesw
ick
Mar
sh
Moo
rclo
se
Mos
s Ba
y
Net
herh
all
St Jo
hn's
St M
icha
el's
Seat
on
Sillo
th
Solw
ay
Stai
nbur
n
Wam
pool
War
nell
Wav
er
Wha
rrel
s
Wig
ton
90 and over 85-89 80-84
75-79 70-74 64-69
% over 65 on AA
WEMWBS
WEMWBS (cont)
Number % Number %Very Poor 0 0.00% Very Difficult 1 0.68%
Poor 0 0.00% Quite Difficult 2 1.35%
Alright 5 3.38% Alright 30 20.27%
Very Good 40 27.03% Quite Easy 68 45.95%
Excellent 103 69.59% Very Easy 47 31.76%
30.57%
85.98%
55.41%Percentage increase in Clients Awareness
Clients Percentage Awareness of Age UK/Concerns Services Before Contact
Clients Percentage Awareness of Age UK/Concerns Services After Contact
Questionnaire 2 Supplimental Data Analysis
Age UK/Concern Service Rating Contacting the Right Help
In the first 3 months after opening C3A there were 141 fewer hospital admissions than the comparable quarter the year before (but a large number of admission avoidance activities are working together to achieve this).
Impact Assessments
Case Studies
• Mr L (£799) v Mr T (£10,319) • Mrs G (£4,385) v Mrs S (£38,484)
• Mr P (£1874) v Mr A (£8503) • Mrs D (-£164) v Mrs K (£5532)
Using a volunteer model? The financial value of volunteering averages around £700,000 per year in Hospital Trusts, £500,000 per year in Mental Health Trusts and £250,000 per year in a Primary Care Trust. Each £1 investment in a volunteering programme yielded an average return of between £3.38 and £10.46 - with these returns shared between organisation, service users , volunteers and the wider community (Teadale 2008) In 2012, work undertaken by NEF and published by the British Red Cross estimated that the money saved was typically at least 3.5 times greater than the cost of the services provided.
What £30,000 has bought in 12 months (10K Pop) Objective: Clinical / improved Care 325 patients signposted/referred to the activities/services of Third Sector organisations 8 sustainable activities which support health and wellbeing set up in the community 250 people attending wellbeing events - e.g. falls awareness, winter warmth 3 sustainable activities to support patients to live well with a long-term condition/dementia Objective: Efficiencies 19 named patients had reduced frequency of GP attendances 36 supported discharges from GP managed beds 38 patients provided with exit strategies from rehabilitation, podiatry etc 38 identified patients who may be at risk were visited, with a comprehensive preventative, holistic assessment 90% of patients attending flu clinics provided with additional wellbeing information
The way forward
What can you do as a person ?
The way forward... Question the notion of ageing; in society, in ourselves Ignore the calendar; chronological age is progressively less
relevant Develop services and products which are appropriate to the
‘third’ and fourth ages’ Think about how we can
– enable life and living – enhance the quality of life – simplify life
What can you do as a Clinician
• Think about the pathway
• Where does the person get “lost” ?
• What could be saved to be re-invented ? • Think about Age UK as a quality partner