Person-centred Integrated Care (PIC) Networks supporting Healthy Ageing in Place

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The UK has an ageing population with increasingly complex health and care needs, linked to growing rates of long-term illness and multi-morbidity that are disproportionately high in the most deprived communities. The resources for formal health and care services such as the NHS and Local Authorities providing social care, are not keeping pace with demand . Prevention of transitions to poor health and higher care needs, and reduction of health inequalities between the most and least deprived groups in society, is essential for the long-term sustainability of the health and care system. The key challenge that we will address is how to prevent or delay transitions to more intensive forms of care as people age, and how to mitigate the impact of those transitions when they do occur. There is a growing evidence that local-level community based support, such as voluntary organisations and connection services such as social prescribing, play a key role in supporting people's health and well-being as they age. Over the past year we have established a multi-disciplinary cross-sector team uniting inputs from medical statistics, health economics, sociology, anthropology and design. Through this collaboration we have developed the concept of Person-centred Integrated Care (PIC) Networks, tailored to existing assets of diverse local settings, as novel interventions to support older people's health and wellbeing as they age in place. This draws on our understanding of the co-design of health and care interventions for communities and the impact of the environment on health and wellbeing as individuals age. This project is proof-of-concept and feasibility research, where we aim to elucidate the role and efficacy of local person-centred integrated care networks in delaying transitions to more intensive levels of care needs, and ameliorating care needs on transition. The study will take the example of the Leeds Neighbourhood Network, which has already been demonstrated to have local efficacy and has been considered by another city council (Birmingham), and explore whether this network model is generalisable, scalable and sustainable.Oxfordshire, the city of Oxford, surrounding small towns and rural communities, has been selected for its diversity of socio-economic and geographic communities in which to test the feasibility of establishing new PIC Networks from the principles of the Leeds model. This project will employ a mixture of qualitative and quantitative research methods across five complementary, concurrent work packages: statistical and economic analysis of population health data sets to develop a set of indicators for evaluation of PIC Networks; qualitative interviews and workshops for stakeholder engagement to identify key people and organisations who might comprise a local PIC Network; design and ethnographic methods to map local assets for potential inclusion in PIC Networks, including the built environment and technological resources, and connectivity between them; and co-creation techniques for citizen engagement on potential outcomes of PIC Network implementation that promote older people's health and wellbeing. Findings from the four concurrent Work Packages will be brought together through two knowledge exchange workshops with key stakeholders, in which we will co-develop and agree recommendations for implementing PIC Networks. This will allow us to devise an appropriate policy agenda which supports inclusively designed PIC Networks as part of a strategy to promote health in later life, and delay age-related transitions into frailty and ill-health.