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Long read

Age UK care co-ordinator roles

Older people with long-term conditions often face a bewildering array of disconnected services rather than joined-up, holistic care. In many cases, older people with a broad range of physical health, mental health and social care needs receive unco-ordinated, sometimes conflicting care, with substantial gaps, rather than personalised support. In the worst cases, and there are many of these, older people shuttle repeatedly in and out of hospital, with no sustainable plan to keep them fit and well, leading to rapid deterioration and a loss of independence many years earlier than necessary.

In 2012, Age UK decided to use its skills and resources to support the health and care system in addressing these problems. The idea was to use Age UK staff to co-ordinate disparate health and care services for vulnerable older people, with a focus on providing holistic packages of care and joining up the support available from health and care services, charities and volunteers. 

The first phase of the project was a pilot care ‘personalised integrated care programme’ for older people in Cornwall. Age UK worked in partnership with general practitioners, community teams and social services to stratify risk in the population and to identify a group of older people with multiple long-term conditions who were at particular risk of unplanned hospital admission. A trained Age UK care co-ordinator held a series of structured conversations with older people on the programme to understand their personal goals, the challenges they were facing, and the type of support they most needed, before working with other services (GPs, practice nurses, social services and others) to develop tailored care plans. Participants received three months of intensive support to help them regain independence, often including some health and care services, support from volunteers, connecting with other older people facing similar challenges and joining community groups. When the programme ends, they are able to keep in touch with care co-ordinators and are encouraged to maintain links with volunteers and the services they have been introduced to when the programme ends. 

The results from the Cornwall pilot were dramatic. There was a 26 per cent reduction in emergency hospital admissions for participants, a 5 per cent reduction in elective hospital admissions and, despite the focus on identifying and addressing unmet needs, an 8 per cent reduction in social care costs. Participants reported an average 20 per cent improvement in their wellbeing, with 20 per cent going on to become volunteers themselves. The programme also provided a catalyst for health care, social care and voluntary sector services to work together in effective partnerships. 

With such positive evidence from the initial pilot, Age UK was eager to extend the programme to a larger number of sites. The financial offer was extremely generous. Age UK was offering to make a substantial investment, asking only for match funding from health and social services. Nevertheless, it struggled to make contact with commissioners and identify localities that were well placed to adopt the programme.

In 2015, Kent Surrey and Sussex AHSN joined forces with Age UK to help address these barriers. It saw an opportunity to help in raising awareness of a successful programme, identifying clinical commissioning groups and localities that would be interested and have the capability to test the programme and establish local partnerships, and developing commissioning cases for the programme. 

Over the next two years, Age UK recruited 14 more sites. It put in place a number of processes to ensure that commissioners and providers were committed to and ready to make a success of the programme, including requirements to establish a partnership across health and social care, to sign an agreement on how the partnership will work together and to provide some match funding. A key commitment is for each of the partners to participate in a monthly board meeting to co-design the service and monitor performance. 

During the initial stage of the projects, the Age UK team works with commissioners and providers to adapt the scheme to the local system. There are a small number of essential components that need to be retained across all sites, for example risk stratification, the structured conversation that care co-ordinators hold with participants, regular multidisciplinary team meetings, and a common performance management and outcomes framework. Beyond this, there is considerable scope to flex the programme to fit with existing services. As the programme has expanded, an important development has been the establishment of a learning forum that brings together the care co-ordinators and partners from all of the sites to compare performance, discuss the challenges they are facing and share ideas about how to make improvements. 

As the pilots have expanded, Age UK and the Kent Surrey and Sussex AHSN have continued to measure the impact of the programme. The new pilots in Kent, Surrey and Sussex have demonstrated improvements in participants’ wellbeing and reductions in use of hospital services comparable to the original pilot in Cornwall. There is evidence that the programme achieves a 600 to 700 cost reduction per participant for the NHS, in addition to the reduction in social care costs. Research by the London School of Economics suggests that £1 invested in the programme delivers £4 in benefits. The Nuffield Trust is completing a large study tracking the impact of the programme for patients over several years.

Care co-ordinators and multidisciplinary teams are now becoming more common in health and social care, with a range of alternative approaches. One of the challenges the team faces is persuading commissioners and providers to adopt their programme rather than alternative models. Perhaps the most striking features of the programme, in comparison with others, are the use of people outside the health and care system for the care co-ordination role, the greater focus on individuals’ overall wellbeing than typical in health and care services, the primary role of non-medical support, and the use of a wide range of low-cost, but hugely beneficial, services to help people regain independence. 

For many participants, the most important benefits of the programme were getting help to walk the dog, regaining confidence to go shopping, being taken out to tea, making friends, and reconnecting with their communities. A key feature of the programme appears to be addressing isolation and disconnection as an underlying cause of health and social care challenges, rather than simply addressing the physical and mental health consequences. One GP mentioned a couple who had not left the house for six months before the programme. It was these issues that, as he saw it, the statutory health and social care services were failing to pick up. 

As the pilots are ending, commissioners are considering whether to commission Age UK’s care co-ordinators on an ongoing basis. One site in Kent has done so, a small number of sites have decided to incorporate principles from the programme into alternative services and other decisions are pending. Despite the convincing evidence of effectiveness, securing small amounts of funding for a low-cost new service remains a substantial challenge.