Ageing Well

The National operating model for Ageing Well and Community Services is based upon system transformation and wider integrated partnerships between Health, Social Care and Voluntary Sector colleagues to better support and promote independence and improved quality of living for people throughout the course of their lives.  To achieve this we will:

• Promote a multidisciplinary team approach with all partners working together in an integrated way to provide a structured model of proactive and holistic care to provide tailored support that helps people live well and independently at home for longer.
• Give people more say about the care and support they receive, particularly towards the end of their lives. Offer more personalised support for people who look after family members, partners or friends because of their illness, frailty or disability.
• Develop more urgent care response teams, to support people with health issues before they need hospital treatment and help those leaving hospital to return and recover at home.
• Offer more NHS support in care homes including making sure there are strong links between care homes, local general practices and community services.

Therefore, NHS England have established three ‘priority areas’ –  Urgent Community Response, Proactive Care and Enhanced Health in Care Homes:

• Urgent Community Response [UCR] – design and development of the two-hour models, including funding any increases in workforce required, refining single points of access, and ensuring there is integration with wider community and urgent care services (including 111) both for referrals in and flow out of UCR.  (See Access to community crisis and recovery services section).
• Enhanced Health in Care Homes [EHCH] – continuing to develop the community health service nursing and therapy input for MDTs to support residents in care homes as part of primary care networks; implementation of advanced care planning; and further improving digital connectivity between the NHS and care homes. (See Comprehensive Geriatric Assessment and Case Management section)
• Proactive Care [PC] – this has received less focus for funding this year, reflecting that the national requirements have been deferred until 22/23. However, places continue to develop their overall approaches and methodologies to population health management, and how they can support integrated care through PCNs.  (See Specific tailored Support for Long Term conditions section).