My care, my way: refining a proactive and holistic care model for over-65s

The traditional, clinical model of care is reaching its limits, with services for older people too often disjointed and unable to meet people’s needs in a holistic way. Within the health and care system we need to radically reorganise care to help more older people stay healthier for longer. Innovation Unit worked with West London CCG and PPL to refine and develop a new integrated model of care for older people. This model is underpinned by an innovative service that has been running across West London for two years – My Care, My Way.

The need
By 2040, nearly one in four people in the UK will be aged 65 or over.  Some 1.2 million people in that age bracket don’t receive the help they need with essential daily living activities, according to data from Age UK.

As the population ages, the limits of the traditional clinical model of care become more apparent. Tackling this problem is especially complex before 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 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 is a new and novel care model that uses risk stratification, proactive care planning and additional local roles to offer a personalised care approach and an alternative to the existing care support and GP appointments.

This 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 impact
The model was launched after an extensive period of co-design alongside patients and staff, and currently operates in 41 GP practices, with 7595 patients on the My Care, My Way caseload and there are 87 staff working in the team.

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 My Care, My Way model. Through a series of 50 ‘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.

The Learning labs process created both material developments to the model and deeper shifts in how professionals approached their work. The time and space for people from different services to work together created energy and a shared sense of ownership. It also planted the seeds of a culture of learning, improvement and collaboration across the service.

Five years on from its business case sign off, the My Care, My Way model has delivered the planned savings, such as through admission avoidance.

Alongside the originally stated aims, there have been a range of other benefits, including, self-reported reductions in GP workload, savings in district nurse and mental health service use, time and cost. The Voluntary Care Sector (VCS) has been better utilized and the consistent usage of self-care has delivered user benefits and a significant social return on investment (SROI).

To find out more, please visit http://mycaremyway.co.uk/