The National Integrated Care Programme for Older Persons’(NICPOP) is leading out on the re-design of the way in which care for the older person is organised and delivered, focussed on the development of an end-to-end pathway that describes cohesive primary, secondary and acute care services for older people with a specific focus on those with more complex needs and frailty.
There is substantial emerging evidence (locally and internationally) that focusing on the management of the needs of the ‘frail older adult’ can produce significant dividends for both the older populations who use them and the systems that serve them (BGS, 2014; NCPOP, 2012).
The National older person’s service model addresses the complete end-to-end patient journey and goes beyond changes to organisational structure. This fundamentally revolves around new pathways, new roles and new ways of working with a specific population focus on older people with complex needs and frailty. Key components of the pathway that are being implemented are (1) Living well with supports (home care, social engagement, transport), (2) access to services within a local Community Health Network (CHN), (3) access to specialist care in the community through a dedicated Older Persons Ambulatory Care Hub and (4) Hospital care based on age attuned pathways.
This involves standardised assessment, bespoke care pathways, appropriate expertise in its management and ensuring key points of contact are made available to older adults and their carers that coordinate care and anticipate ongoing needs.