Based in the six GP practices of Newcastle-under-Lyme South locality, the project was designed to offer improved care and support to all people who were:

  • Aged over 85 years
  • Housebound
  • Diagnosed with dementia
  • Aged between 75 and 84 years and identified as potentially benefiting from further support as a result of a screening process.

These selected groups of older people were offered a personal visit by a named Elderly Care Facilitator, who completed a holistic assessment of needs and developed a personalised action plan for each individual. The action plan was intended to help people to access suitable care and support, to promote collaborative working between services and to enable supported self-care.

The project had four main objectives:

  1. To offer proactive holistic assessment and early intervention for older people, in order to encourage healthy ageing and support self-care.
  2. To maximize interagency working and explore new ways of working, specifically by developing the role of a practice based Elderly Care Facilitator to lead and coordinate an approach focusing upon offering personalized support for each individual older person.
  3. To achieve positive outcomes for older people in a wide range of different areas, including health and well-being, as well as other aspects such as safety, security and financial well-being.
  4. To use the learning from the project to support further developments in delivery of care for older people, by:
  • Identifying local resources
  • Extending public and professional knowledge of them
  • Assessing medical and social benefits of the project
  • Understanding the workload and costs involved in taking this proactive approach.

To read the full project reportĀ click here