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Keeping older people healthy and well at home—collaboration is key

Tamsin Fulton, 12 December 2014

Keeping people healthy and well at home for longer is a key driver for integrated health and social care and major initiatives are underway to shift activity and resources into the community.

That seems to put GPs at the heart of the health and social care economy, but the landscape is much more complex than that  - particularly for older people and their carers.

As well as GPs, in the care mix we see home care workers, community nurses, allied health professionals, social workers, geriatricians, nutritionists, dentists, community mental health teams, dementia nurses, meals-on-wheels staff, befrienders, advocates, family & informal carers, other relatives, clubs, groups and day centre staff and volunteers.

In fact, that is possibly just a starter list and many combinations of groupings of these individuals will be contributing to an older person’s care at any one time, particularly with so many older people with more than one acute condition.(Co-morbidities are at 50% amongst 65-year-olds, rising to 75% of 75-year-olds).

Arguably, however, the specialist at the heart of these complex relationships with her client is not the GP but the home care worker -- and according to a recent CQC survey, carers said choosing care is one of life's most stressful events.

Of all the staff and volunteers who see an older person, it’s often the care worker who has by far the most potential for regular contact. I say “potential“ because we know that care worker continuity is far from assured, which means that the ability to form relationships with clients is also compromised.

But if that could change then care workers are ideally placed to assist the prevention agenda, being able to affect, as they can through daily routines, a person’s behaviours and habits, as well as to spot early needs before they escalate.

What does an effective model of home care look like and how it should work as an integrated part of the wider health and social care economy?

In terms of prevention and helping people keep healthy and well at home we can just start with the top reasons why older people get admitted to A&E -- namely falls and urinary tract infections -- to see which kinds of practical support care workers could provide.

Making sure the older person has access to fresh water during and between visits, does not need to climb on a chair to change a light bulb, or watching out for early signs of cellulitis are examples of the important roles care workers can play.

This would make a huge contribution to reducing A&E admissions -- but they can do that only if, in collaboration with GPs and nursing staff, they know what to look for, what to do and who to contact.

The Malnutrition Taskforce 2013 estimates 1 in 10 people over 65 are malnourished or at risk and in over 75s the risk of malnutrition is projected to double in the next 30 years. This is a condition that rapidly contributes to acute illness or deterioration in ability to manage life at home.

Supporting older people to eat well -- whether that’s cooking a meal with fresh ingredients, organising shopping or getting a person along to lunch clubs -- would all help in very practical ways to combat malnutrition.

And this is just the health bit of health and wellbeing. Preventing isolation amongst older people is also an urgent challenge.

We know isolcation of care workers is also an issue -- a Unison survey found most home care workers did not see a colleague on a daily basis. This undermines morale and impacts on the ability of the home care worker to learn and develop in the role.

So building strong collaborative networks between care workers and clients where capacities, budgets and services could be shared or pooled would offer opportunities for social interaction and new friendships.



Being active and engaged in the community is a well-known indicator of wellbeing. Bromley-by-Bow Centre has been championing the concept of Social Prescribing, where people can prescribe social activities, such as lunch clubs, befriending and strength & balance exercise classes.

Suffolk Council’s recent survey with service users and family carers found 41% thought it very important (6/6) that their carer knows their local community. Care workers knowledgeable about the local area, knowledgeable about what to do and where to go, and who are deeply embedded in the local fabric -- such a service would make significant strides to realising wellbeing at home.

Simply commissioning home care as a stand-alone service will only add to the fragmentation of care and not bring about this radical shift to greater health and wellbeing at home. Care workers must be able to collaborate with individuals and teams from health and social care and the voluntary sector to design and deliver the best outcomes.

Collaboration across the organisational boundaries of primary care, community, acute and voluntary sector services is necessary to establish a successful relationship-based model of integrated home care.

We need collaboration over a period of time to explore new routes to health and wellbeing at home that draw on the creative capacities of people from across the system, and that seek to strengthen rather than fragment precious resources.

A collaborative approach will build the foundation for preventative care at home and provide a blueprint for commissioning home care services of the future.

This is a call for collaboration where the costs, risks and outcomes are shared across all parties so that:

  • People who need care and support get the best outcomes for their health and wellbeing;
  • Frontline staff and volunteers explore how new and existing teams can work better together;
  • New models of training and support can be devised that will motivate and develop the workforce;
  • New integrated funding models can be devised and commissioned.

Tamsin Fulton is an Associate Consultant with Public World.

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