Thematic review which looks at how well care for older people is integrated across health and social care, as well as the impact on older people who use services and their families and carers. The review collected evidence from eight areas site visits, reviewed care records, spoke to older people and their carers, and held focus groups with staff. It also looked at examples of where care was coordinated effectively and identified barriers that prevent it from working well. It discusses findings around three areas: identification and prevention, covering how well older people with complex needs or at high risk of deterioration are identified; person-centred assessment and planning; and care coordination. Key findings included that there was a widespread commitment to developing and delivering coordinated care. However, organisational barriers such as a lack of consistency in the use of assessments and in the sharing of information made it difficult for services to identify older people who were at risk of deterioration or an unplanned emergency admission. Older people often had multiple care plans and there was lack of knowledge among professionals of how care plans should be written and reviewed. The review also found insufficient monitoring and evaluation of many of the initiatives in place to improve integration. Where integrated, person-centred care succeeded, local leaders worked closely across health and social care services to share information, reduce duplicated efforts and use resources more effectively. Recommendations include: the development of a methodology and data set for identifying people at risk of admission to secondary care; and the development of a set of validated data metrics and outcomes measures for integrated care.
(Edited publisher abstract)
Thematic review which looks at how well care for older people is integrated across health and social care, as well as the impact on older people who use services and their families and carers. The review collected evidence from eight areas site visits, reviewed care records, spoke to older people and their carers, and held focus groups with staff. It also looked at examples of where care was coordinated effectively and identified barriers that prevent it from working well. It discusses findings around three areas: identification and prevention, covering how well older people with complex needs or at high risk of deterioration are identified; person-centred assessment and planning; and care coordination. Key findings included that there was a widespread commitment to developing and delivering coordinated care. However, organisational barriers such as a lack of consistency in the use of assessments and in the sharing of information made it difficult for services to identify older people who were at risk of deterioration or an unplanned emergency admission. Older people often had multiple care plans and there was lack of knowledge among professionals of how care plans should be written and reviewed. The review also found insufficient monitoring and evaluation of many of the initiatives in place to improve integration. Where integrated, person-centred care succeeded, local leaders worked closely across health and social care services to share information, reduce duplicated efforts and use resources more effectively. Recommendations include: the development of a methodology and data set for identifying people at risk of admission to secondary care; and the development of a set of validated data metrics and outcomes measures for integrated care.
(Edited publisher abstract)
Subject terms:
integrated care, older people, health care, social care, carers, care planning, person-centred planning, assessment, joint working, interagency cooperation, good practice;