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

英国人口老龄化，健康和护理需求日益复杂，与长期疾病和多种疾病发病率的上升有关，而在最贫困的社区，这一比例高得不成比例。用于正规保健和护理服务的资源，如NHS和提供社会护理的地方当局，没有跟上需求的步伐。防止向健康状况不佳和更高的护理需求过渡，并减少社会中最贫穷和最贫穷群体之间的健康不平等，对于保健和保健系统的长期可持续性至关重要。我们将应对的关键挑战是如何防止或推迟随着人们年龄的增长向更密集的护理形式过渡，以及当这些过渡确实发生时如何减轻它们的影响。越来越多的证据表明，地方一级以社区为基础的支持，如志愿组织和社会处方等联系服务，在支持人们随着年龄增长的健康和福祉方面发挥着关键作用。在过去的一年里，我们建立了一个跨学科的跨部门团队，将医学统计学、卫生经济学、社会学、人类学和设计学的意见结合在一起。通过这种合作，我们开发了以人为中心的综合护理(PIC)网络的概念，为不同当地环境的现有资产量身定做，作为新的干预措施，支持老年人在适当年龄时的健康和福祉。这得益于我们对社区健康和护理干预措施的共同设计以及随着个人年龄增长环境对健康和福祉的影响的理解。这个项目是概念验证和可行性研究，我们的目的是阐明以人为中心的本地综合护理网络在延迟向更密集的护理需求过渡以及在过渡期间改善护理需求方面的作用和有效性。本研究将以利兹邻里网络为例，探讨这种网络模式是否具有通用性、可扩展性和可持续性。牛津郡、牛津市、周边的小城镇和农村社区因其社会经济和地理社区的多样性而被选中，以检验根据利兹模型的原理建立新的PIC网络的可行性。该项目将在五个互补的并行工作包中采用定性和定量研究方法：对人口健康数据集进行统计和经济分析，以制定一套评估PIC网络的指标；针对利益相关者的参与，进行定性访谈和研讨会，以确定可能构成当地PIC网络的关键个人和组织；设计和民族志方法，以绘制潜在纳入PIC网络的当地资产图，包括建筑环境和技术资源，以及他们之间的连接；以及共同创造技术，让公民参与PIC网络实施的潜在结果，促进老年人的健康和福祉。来自四个并行工作包的结果将通过与主要利益攸关方举行的两个知识交流研讨会汇集在一起，在研讨会上，我们将共同制定和商定实施太平洋岛屿国家网络的建议。这将使我们能够制定适当的政策议程，支持包容性设计的PIC网络，作为促进晚年健康的战略的一部分，并推迟与年龄有关的向虚弱和健康不良的过渡。

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.