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Age UK Integrated Care
GP Education EventRoyal Surrey County HospitalThursday 28th May
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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
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Community Support
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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
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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
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Example Smart Goals
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www.knowledgebucket.org
http://youtu.be/V5VsqSiHYVY