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

联合王国人口老龄化，保健和护理需求日益复杂，这与长期疾病和多种疾病发病率不断上升有关，而在最贫困的社区，这种发病率高得不成比例。正规保健和护理服务的资源，如国民保健制度和提供社会护理的地方当局，跟不上需求。防止过渡到健康状况不佳和保健需求增加，减少社会中最贫困和最不贫困群体之间的保健不平等，对于卫生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，如何防止或延迟人们随着年龄的增长向更密集的护理形式过渡，以及当这种过渡确实发生时，如何减轻这种过渡的影响。越来越多的证据表明，以地方一级社区为基础的支持，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，我们建立了一个多学科、跨部门的团队，汇集了来自医学统计学、卫生经济学、社会学、人类学和设计的投入。通过这种合作，我们开发了以人为本的综合护理（PIC）网络的概念，根据不同地方环境的现有资产量身定制，作为支持老年人健康和福祉的新干预措施。这借鉴了我们对社区健康和护理干预措施的共同设计以及环境对个人年龄增长的健康和福祉的影响的理解。该项目是概念验证和可行性研究，我们的目标是阐明以人为本的地方综合护理网络在延迟过渡到更密集的护理需求水平以及改善过渡期间的护理需求方面的作用和功效。该研究将以利兹社区网络为例，该网络已经被证明具有当地功效，并已被另一个市议会（伯明翰）考虑，并探索该网络模式是否具有普遍性，可扩展性和可持续性。牛津郡，牛津市，周围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，以测试从利兹模式的原则建立新的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混合的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，以制定一套评价知情事先同意网络的指标；为利益相关方提供定性访谈和研讨会，以确定可能组成本地PIC网络的关键人员和组织；设计和民族志方法，绘制可能纳入PIC网络的当地资产，包括建筑环境和技术资源，以及它们之间的连接；以及共同创造技术，促进公民参与知情同意网络实施的潜在成果，促进老年人的健康和福祉。四个同时进行的工作包的成果将通过与主要利益攸关方的两次知识交流研讨会汇集在一起，我们将在研讨会上共同制定和商定实施知情同意网络的建议。这将使我们能够制定一项适当的政策议程，支持包容性设计的知情知情网络，作为促进晚年健康和推迟与年龄有关的向虚弱和健康不良过渡的战略的一部分。

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.