Refining a proactive and holistic care model for over-65s

As the population ages, the limits of the traditional clinical model of care become more apparent. Tackling this problem is especially complex because care for older people is no single organisation’s responsibility – health and social care services have evolved separately so that medical, social, emotional and psychological needs are met by different organisations.

There is a consensus that to fully meet the needs of our ageing population we need to radically rethink how care is organised. We need to move from a set of services which focus on fixing people, to an approach which helps them to care for themselves, and which makes the most of resources available within the wider community and family networks.

In 2015, West London CCG set up My Care, My Way (MCMW) in response to feedback from local people which indicated that too many were dissatisfied with the fragmented model of care for the over-65s. They wanted a new approach.

My Care, My Way offers a holistic system of health and social care for older people, built around four core elements:

• Two new patient-facing roles based in GP practices. Case managers and health and social care assistants provide all people over the age of 65 in West London with a single point of contact into the health and social care system, someone they trust that can help them to gain quick access to the support they need.
• Multi-disciplinary assessments and extended appointments. More vulnerable patients are given access to extended hour long appointments with their GP as well as being invited to hour long assessments with a range of different professionals (including their GP, a social worker, a Geriatrician and a Pharmacist), allowing all parties to build a rich picture of the person’s needs and aspirations.
• A whole system focus on self care and social prescribing. Through the development of patient facing care plans, and the provision of a wide range of social prescribing opportunities, all patients are encouraged and supported to manage and improve their own health and wellbeing.
• A whole system focus on prevention. As well as working with patients with more complex health needs in order to manage or avoid moments of crisis without too much disruption or loss of independence, MCMW staff work with less complex patients who might be at risk of slipping into poor health.

The model was launched after an extensive period of co-design alongside patients and staff, and currently operates in 24 out of 40 GP practices in West London. As with any innovation, the journey of taking the service from idea to reality has been complex, and the programme team sought support to engage staff in tackling some of the challenges of implementation.

Over four months we worked with frontline practitioners across primary, community, social and acute care, and the third sector, to rapidly develop, refine and improve the MCMW model. Through a series of “Learning Labs” we set out to empower staff to identify and make their own changes to the model, and to create materials that would ensure these changes were sustainable.

We started by identifying nine typical MCMW practices as the focus for problem solving through the Learning Labs. Over a two month period teams took part in weekly workshops to understand the causes of the problems they were experiencing (e.g. the way the hubs were being used, the relationship between MCMW staff and district nurses) and to come up with potential solutions. They then rapidly tested these new ways of working in real life.

Three improvements emerged from the Learning Labs:

• Anticipatory, patient-facing care plans, designed to help keep people out of hospital
• Multi-disciplinary email team meetings between MCMW staff and other services, enabling holistic working without everyone having to be in the same room
• Priority case lists – helping to  focus attention and effort in order to prevent and manage crisis’

A new My Care, My Way Quick guide and service blueprint takes these and sets out what the service looks like at its best.

Beyond material developments to the model, the Learning Labs process also created some deeper shifts in how both GPs and MCMW approached their work. It gave space and time for professionals from different services to work together and create new solutions. It created energy and a shared sense of ownership, and planted the seeds of a culture of learning, improvement and collaboration across the service.

What next?

The My Care, My Way model has made a real difference to patients and professionals across West London. But challenges remain, and not least the relationship between My Care, My Way staff and other professionals working with older people in West London (from District Nurses and Social Workers to Geriatricians and Dementia specialists). Over the next two years, the CCG and its partner will be confronting this challenge head on by bringing a range of these professionals together into a single integrated community team, that will work in and with practices to meet the needs of the older adult population.