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Integrating Care for Older People: New Care for Old - A Systems Approach

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The authors of this text share their practical experience on implementing a multi-agency approach to the support of older people. The show how systems thinking can help with the complexity of developing a model of care that co-ordinates medical, social and community services. They offer insight into the effective use of on-going assessment, evaluation, costing and information technology, with examples.They demonstrate how they achieved a ''one-stop'' rapid response to emergencies and a multi-level approach to risk management. They also show how enabling the older person to become an equal partner in decision-making, both as an individual user and as a citizen, reduces dependency, and can prevent current problems such as overlap and duplication of service and inappropriate admission to hospital and residential care. Models of consultation are included, along with guidance on running participatory groups.The resource seeks to meet the growing need for material on multi-agency practice and should be a useful tool for all those working across organizational and professional boundaries to deliver an integrated care system for older people.
Foreword, Preface: Introducing Emily. 1. The Roots of Discrimination. 2. Systems 3. Implementation Models. 4. Getting to Know the Older Person: Assessment. 5. Crisis, Risk and Chronic Disease Management 6. Putting it in Place: Some solutions. 7. Connecting Places: Applying information technology 8. Involving the Users 9. Evaluating an Integrated Care System 10. Levers and Tools for Developing an Integrated Care System. 11. The New Professionals. 12. Changing Places: The way ahead for the care of older people. 13. End of Life. Epilogue: The New Emily. Appendices. References, Index.
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