New Models of Care

This work-package is how all the other work-packages translate into the real world. Drawing on the initial findings of all the research work-packages, we will co-create new models of care which are grounded in detailed understanding of individual need, which use existing data and predictive tools to support categorisation of individuals' risk levels. This categorisation will flexibly incorporate proven new technologies as they become available, integrated within existing health and social care services. 

New Models of Care is a collaboration with colleagues from Newcastle University’s Institute for Ageing, which hosts the National Innovation Centre for Ageing. Our collaboration with this world-leading research Institute and centre at Newcastle University greatly strengthens the networking opportunities for the ACRC and thus future funding opportunities for both Universities. 

What are our intentions?

The overall aim of this work-package is to work with health and social care providers to support and evaluate the development of new models of integrated care. To do this we need to understand existing and evolving models of care, and to develop, optimise and test innovative new models of care in Scotland and England. Specifically, we are interested in identifying variation both early in the trajectory of care when interventions are less intensive and more directed to self-management at home, and later when more intensive interventions and residential care are more common. Given that health and social care policies have commonalities but also significant divergence between the two countries, our objectives are: 

Objective 1: to study the international changes in health and social care systems in response to the global challenges of ageing populations, multimorbidity, and frailty, and to relate these findings to the evolving health and social care integration and reorganisation of primary care in Scotland and England, and the intended and actual impact on those with complex care needs 

Objective 2: in the context of objective 1, to explore multidisciplinary team care for people in later life with a spectrum of care needs in South East Scotland and North East England, identifying examples of innovative practice in community and primary care, and barriers and facilitators to change in areas where care has not significantly evolved. Selected examples will then be examined in-depth.

Objective 3: to synthesise findings in collaboration with health and social care stakeholders and public/patient partners to design new models of care for implementation and evaluation at scale. 

Objective 4: To submit a series of major grant proposals to rigorously test these new models of care in terms of effectiveness, safety, and cost-effectiveness.   

We will focus on four areas that influence key care pathways in this work-package.  

1. Community and third-sector support for people in later life living in the community 

2. Integration of statutory health and social care services for people in later life living in the community 

3. Transitions into care homes  

4. Improving the care of those already living in care homes 

Why is this important?

Health and social care in the UK is in a state of rapid change with major initiatives in health and social care integration, primary care reform and new general practice contracts, supporting self-management, and better targeting of new kinds of statutory and third sector care. There are also considerable opportunities for collaborative working to shape and evaluate new models of care as they emerge in service innovation and/or are developed as part of research. 

Two key developments in many areas of the UK relate to the use of asset-based approaches to care, and developing more multidisciplinary comprehensive assessment and intervention for people with the highest care needs. Implementing a new service model brings many challenges, and new tools for sharing information about services have the potential to help break down some of the traditional barriers to self-care and autonomous decision making in this context. Such democratisation of knowledge, that promotes individuals themselves as experts in knowing what will work for them in their lives, is critical.  

How will we achieve this?

These objectives will be carried out by researchers at the Universities of Edinburgh and Newcastle:

1. This work-stream will involve reviewing the international literature, and English and Scottish policy documents. Interviews will also be conducted with key stakeholders. The aim of this work-stream is to gain comprehensive and up-to-date knowledge of the international and UK landscape regarding new models of care in community and primary care settings across our 4 areas of focus. This work-stream will be completed in the first 12 months of the project.

2. This work-stream will involve gathering local information on established or evolving innovative approaches for target groups of patients in South East Scotland and North East England, in order to identify and document in-depth examples of new models of care across our four areas of focus. We will combine qualitative interviews with quantitative approaches. The time-line for this will be months 6-18.  

3. This work-stream will integrate and synthesise the findings from the previous work-streams and will also incorporate emergent developments from the other work-packages. We will use a co-design approach to develop and optimise new models of care for evaluation and implementation at scale. The aim of this work-stream is to have a range of rigorously developed interventions across our four areas of focus ready for testing at scale. The time scale for this will be months 18 – 30. 

4. To submit a series of major grant proposals to test these new models across our four areas of focus of care at scale in terms of effectiveness, safety, and cost-effective. Time-scale for grant submission is 30-36 months. 

Meet the Team: New Models of Care