Personalised Integrated Care Programme
All too often older people living with long-term conditions do not have a sustainable care plan to keep them out of the hospital. Launched in Cornwall in 2013, Age UK’s Personalised Integrated Care programme uses risk stratification to both identify those older people who are at risk of recurring hospital admissions and provide a combination of medical and non-medical support. This support starts with a 'guided conversation' between the older person and an Age UK Personal Independence Co-ordinator. In this conversation they outline the goals that the older person identifies as most important to him or her and they draw a care plan which will include a combination of voluntary, health and care organisations. Following this, an Age UK volunteer is matched with the older person, both to help in achieving his or her goals, but also to encourage them to be more independent in managing their own care ...