Proposal

The Ageing Well Network has established a working group which brings together many of the key people concerned about this issue from the health care and home care areas, and from the public and private sector.

The aim is to develop a new approach to supporting older people to remain in their own homes. This new approach will involve greater integration of health and social services as a way to improve effectiveness and efficiency of service delivery, particularly for older people with multiple needs and interactions with many professionals, services and organisations.

Such integration would improve continuity of care as well as client health and satisfaction, while reducing the use of costly resources, like hospitals and other institutions. The approach will involve a number of key features (see appendix 1). Under the proposed new approach:

1. There will be coordination between decision-makers and managers at the regional and local levels and the system would be located in the HSE’s LHO/Primary Care Centres
2. The older person will have a single entry point into the system but there will also be multiple sources of reference into the system eg GPs, Service Brokers -Cultaca, NGO groups, family, individual themselves
3. A designated Care Manager will carry out an initial assessment and call in additional professionals as required, to conduct multi-issue assessments
4. A Single Needs Assessment instrument will be used covering physical and mental health, social care, connectedness, the house, ability to be out and about
5. Individualized service plans will be developed
6. A computerized clinical chart will be introduced to facilitate communication between institutions and clinicians.
7. All older people will be eligible to use the system, although the amount paid will vary according to ability to pay.