Integrated Care Programme
- Location: Age UK Lancashire
- Price: Free
Email: ageukintegrated.carereferrals@nhs.net
Telephone: 0300 303 1234
This service supports people aged 50+ who are at risk of unplanned hospital admissions, have a high frailty score or any number of long-term health conditions. It helps them to access services or support which then helps them manage their conditions independently and maintain their independence.
How the service works.
Personal Independence Coordinators (PICs) work with patients to identify goals and aspirations which matter to them. PICs liaise with the patient and other services to create a personalised plan that suits the patient’s lifestyle, enabling them to enhance their health and wellbeing and regain their independence.
Typically, the plan includes addressing an individual's physical and mental wellbeing needs, setting personal goals to work toward during a 12-week support phase. This approach empowers older people to recognise and develop their own strengths and abilities and helps patients to take actions that enable them to lead lives that are independent and as fulfilling as possible.
Who qualifies for this service?
Patients aged 50+ living in East Lancashire, with an elevated risk of unplanned hospital admission (based on clinical judgement), this could include any number of long term conditions, unplanned admissions, a high frailty score of 5 or above, needing high level intervention or upon discharge (either through Integrated Discharge Service (IDS) or direct from wards).
How to access this service.
The Service will accept referrals from the below list, though the list is not exhaustive:
Integrated Discharge Team
GP’s
Social Services
Social Prescribers
GP's
Other Health Professionals
Age UK Lancashire Hospital Aftercare Service
Other VCFS services working within Intermediate Care.
The service typically operates between 9-5pm, Monday to Friday.
Making contact.
Referrals will be accepted via email, telephone or post. A referral form is available in both word and EMIS formats.