Providing the right care and support where it’s needed most

Members of the Age Well project team at work

Frail and vulnerable older people in our county are receiving targeted support to live independently under a new initiative launched by Northamptonshire Health and Care Partnership.

Age Well Wellingborough is a pilot project which brings key health, care and voluntary organisations together in one place to provide personalised assistance for local over-65s who need it most.

Wellingborough has an above-average elderly population and statistics show that older people in the town are more likely to need to be admitted to hospital or require social services support.

The aim of Age Well is to identify those most at risk of hospitalisation, contact them to understand their needs and then make use of the county’s range of existing health and care services to offer them support.

Launched in December 2018, the project will run until 2020 and could potentially be expanded around the county if successful.

Mark Major, chief executive of Northamptonshire Carers, which is co-ordinating the initiative on behalf of NHCP, said: “Age Well is a great example of partnership working at its best – it’s a number of organisations coming together to work in a more holistic way, making the best use of the services we already have in our community to support older people in need.

“People can be vulnerable for all sorts of reasons. They might be socially isolated, struggling to cope with dayto- day tasks, or maybe juggling caring responsibilities alongside their own health needs. By co-ordinating our response in this way we stand a much better chance of finding them the right help at the right time to support them to stay well and live independently.”

Age Well Wellingborough is a collaboration between Northamptonshire Carers, Age UK Northamptonshire, Kettering General Hospital, Northamptonshire Healthcare Foundation Trust, local GP practices, Northamptonshire County Council’s adult social services and public health teams, Borough Council of Wellingborough and Care & Repair home improvement agency.

Age Well: a day in the life

Derry Miller

Each day for Age Well Wellingborough sees members of the project team gather in their office at Albany House Medical Centre.

There they go through a list of older patients discharged from Kettering General Hospital the day before – along with any others who may have been referred to them by GPs, district nurses or local pharmacies – and give those patients or their carers a call to offer their support.

Where the need is identified a member of the Age Well team will be allocated to work with that person to provide the support they require. With such a broad range of skills and backgrounds in the room, there’s plenty of scope to help people – and often they can visit them the same day if their need is immediate.

Records are then updated to ensure GPs are kept informed of their patients‘ needs and the services they have received.

“The sorts of problems we’ve encountered have been very different – but people just like the fact that we’re out there and are taking the time to ask,” says project lead Derry Miller.

“It’s very much an evolving project but we want GPs and district nurses to know we’re here as an extra resource – and an effective part of providing good care for the people concerned.”

“It was just about getting over that hurdle”

Betsy Innes

Every Age Well story is different. For one elderly couple identified by the project, the husband, suffering from heart problems, was in need of some respite from caring responsibilities for his wife, who has dementia.

When Age Well project worker Betsy Innes visited their home, she knew some friendly persuasion might be required.

“For many people just the mention of a day centre can be off-putting because they see it as old people sitting around, doing nothing and being dreary,” says Betsy.

“So when I went out with permission from the doctor to speak to her I said to her, look – why don’t we go out for lunch, just you and me? She agreed and we had a lovely three-course lunch, she played bingo and they had a raffle. She thoroughly enjoyed it and wanted to go back.

“Now we’ve arranged with her daughter for her to go every week. It gives her husband time to rest and he’s not worried because she’s in a safe environment. It was just about getting over that hurdle.”