Traditional models of care have tended to focus upon the organisations and services designed to meet ‘vertical slices’ of need along an individual’s trajectory of need, with multiple hand-offs of care, from primary care to intermediate care to acute care and back again. Traditional models have also tended to focus upon the care provided by health and care organisations and services, without fully recognising or emphasising the potential contribution of self-care and supported self-care at every stage of the journey.
There are complex interactions between the health and care events along an individual’s journeys of care that together determine that person’s overall experience and outcomes of care. In other words, it is not just the total number of health and care events that people experience that is important, but the characteristics of the individuals who experience these events and the combinations in which they occur for different individuals and within their personal circumstances.
Individuals may experience many and varying numbers and combinations of secondary and specialist care interactions. However, primary care and, to an even greater extent, self-care should be universal experiences for people with frailty, and are therefore a much better starting point from which to follow an individual’s journey of care. Reframing the approach to the frailty pathway to align with a longitudinal view of individual journeys of care, rather than taking cross sectional views aligned to the differing perspectives of organisations and services at various points along the journey, is therefore likely to help improve the individual experiences and outcomes of care for older people living with frailty.
Therefore, in order to achieve integrated care along the entire journey of frailty and throughout the full trajectory of need, it is more helpful to construct services in ‘horizontal layers’ with firm foundations in the continuity of self care and primary care at every stage of an individual’s journey. Considering service provision in this way also helps to understand why, in the absence of service redesign, as baseline needs related to dependency, frailty and disability increase, there is a shift in demand towards secondary care, even without increased acuity. In order to counteract this shift, services to support self-care, primary care services and services designed to meet transitional levels of need must all be redesigned to have the capacity and capability to effectively support individuals with higher levels of frailty, and more complex needs, than can be currently accommodated within these services.