AgeWell – Sustained peer engagement, monitoring and early detection supports healthy aging at home

Description

AgeWell began as a pilot in 2018, where it focused on supporting older people in and around Summerhill Village and the surrounding towns and townlands. The success of this initiative locally led to its expansion eventually to all of County Meath. To date 461 older people have availed of and benefitted from its supports.

AgeWell clients are isolated, lonely, vulnerable, and at-risk older people living in Co. Meath. AgeWell supports them to remain in their own homes and communities for longer.

AgeWell is a unique care coordination model for older people. In November 2022, Professor Amanda Phelan published a report ‘AgeWell Programme as a public health intervention’. In it she described AgeWell as ‘an example of re-imagining care in the community by creating support networks for older people to potentialize health and springboard onward, timely referrals to formal health and social care services’.

AgeWell combines sustained peer-based social engagement and mobile technology to improve health outcomes and well-being among older people. The model combines the best practice of several care coordination models and includes the following key elements:

• Recruitment and training of people aged 50+ as AgeWell volunteer companions.
• AgeWell Companions provide social engagement through weekly home visits and phone calls.
• AgeWell Companions utilise a phone-based App (20/20 App) to capture health, wellbeing, and related information about their clients. The App has a series of questions and observations asked on a fortnightly basis, designed to pick up on any changes, or deterioration in a client’s physical, emotional and psychological health and wellbeing.
• The App also monitors changes in mood, general health, and wellbeing, social contact, access to services, and any new symptoms occurring such as confusion, changes in mobility, falls, decline in appetite, pain, or hospitalization.
• The platform processes the information using referral algorithms to generate suggested actions to explore with clients.
• AgeWell acts as an early warning system identifying and addressing evolving health, social and environmental problems before they escalate.
• AgeWell promptly links clients to appropriate services as needed.

AgeWell has a Care Coordination Team that provides support to the AgeWell Companions. Any causes for concern picked up by the Companions and the 20/20 app will trigger referrals. These are received by the AgeWell Care Coordinators who assess these issues and respond appropriately. The Care Coordinators conduct initial client assessments (Baseline), and quarterly (Midline) assessments thereafter. Client assessments use the following scales WHO5 (wellbeing), MOSS 8 (informational and Emotional Supports), and the UCLA (Loneliness scale). They measure clients’ self-rated health and physical activity levels. Programme evaluations are carried out to measure the impact of the service. This was particularly useful during the pandemic as AgeWell could track the impact of Covid-19 specific support measures.

AgeWell’s development has been driven by the needs of its clients. Ongoing service evaluations and reports from the Companions create a unique awareness of the emergence of new trends, development of new needs, and the impact and effectiveness of the programme. AgeWell Companions participate in monthly support and information meetings which facilitate Information sharing, support, and discussions on emerging needs. Scheduled training and CPD for both Staff and Companions take place every 2 months.

AgeWell provides a tailored support service for each client. They carry out a landscape analysis in each location that they operate, and link clients to appropriate primary care providers, social services and community resources and services. Continuous communications and updates from the Companions enables AgeWell to react to emerging needs quickly. They regularly link clients to Third Age’s menu of services and supports including health and holistic treatments (Chiropody, Audiology, Counselling, Reflexology), group and social activities (creative pursuits, exercise and activity classes, Life-long learning opportunities), peer listening support via the SerniorLine service.

In an increasingly diverse Ireland where residents and citizens of all ages are increasingly being drawn from multi-ethnic backgrounds AgeWell can, if requested, link clients who need language and integration supports directly to the Fáilte Isteach programme. Fáilte Isteach now has over 250 classes operating each week throughout the 26 counties of the republic. It supports over 7,000 migrants, IPAs and refugees from 80+ nationalities in communities, Reception Centres and Direct Provision nationwide weekly. As with all Third Age programmes the classes are flexible, learner-centered, free and provided by older volunteers.

AgeWell reduces isolation and loneliness, improves wellbeing, informational and emotional supports, physical activity levels, self-reported health. It captures evolving health issues before they escalate and connects older people into the right service at the right time. AgeWell assist those living with chronic conditions to manage their health better and improve their chances of participating in physical and social activity in their community. AgeWell provides ongoing health and well-being monitoring and is a cost-effective healthcare model that identifies and reacts to health, social and environmental risks and supports older people to live well and age better.

Aim of Initiative

To support older people living in Co. Meath to live well for longer in the place of their choosing though the provision of sustained peer engagement, support, monitoring, and the early detection and response to changes in health, social and environmental problems before they escalate into something more serious. To reduce isolation and loneliness through weekly visits and phone calls. To connect older people to the right support services at the right time.

Who is it aimed at

AgeWell is aimed at supporting older people throughout Co. Meath to live well for longer in the place of their choosing. They work with older people who are frail, isolated, lonely, vulnerable, at-risk and in-need. The service is available to people aged 60 and over, currently the mean age of their clients is 83, 67% of clients are over 80, and 36% are over 85 years old. 70% of Clients are Female, and 65% are widowed. Referrals to the service come from different sources, currently 39% are via self-referral, 30% via a healthcare provider or professional, 16% via a friend or family member, and 15% from other community services and supports.
AgeWell also involves older people as volunteers providing a unique peer-to-peer aspect to the service, and enabling older people to make a real and lasting difference to those who are in need of support in their communities.

3 Steps critical to success

1. Initially building the right team to lead and roll out the project. The Manager of the programme came from a nursing and healthcare background. They recruited a competent and capable team of Care Coordinators to support the programme whose expertise included care giving, technology, volunteering and community programmes and working specifically with older people. It was extremely important to have the right skills and experience in the AgeWell team to ensure the successful development and expansion of the service throughout the County. Also the team of volunteers (AgeWell Companions) who support clients, their dedication, professionalism, understanding and kindness enhances the programme. Also Third Age’s ethos of innovation, its experience working for and with older people and its practical and pragmatic can do attitude.
2. The buy-in and support from the HSE and the Director of Nursing in Meath, without whose support the project would not have succeeded. They supported AgeWell with funding to pilot the initiative and helped to promote the service within their networks particularly among the Primary Care Teams and PHN’s. Currently 30% of referrals to the service come from healthcare professionals and services. Also buy-in from other community groups and services. AgeWell carry out a landscape analysis in every location in which they provide support, and buy-in from other support services allows them to tailor the support that each client receives and creates additional referral pathways.
3. Financial and other support from past and current funders, supported Third Age to move AgeWell from a pilot in and around Summerhill village, to the countywide service that the programme is today. AgeWell are very grateful to the HSE, Meath County Council (through the Capital Enhancement Programme and the Healthy Ireland Fund), Slaintecare, Community Foundation for Ireland and Social Innovation Fund for believing in the work, and recognising the benefits that AgeWell provides to older people, the peace of mind it provides to their loved ones, and the importance that it plays in keeping older people safe and well for longer in their own homes and communities.

3 Challenges in Planning / Delivery

1. Covid-19 posed a challenge in terms of safety of both clients and Companions. AgeWell repurposed the model to introduce Covid-19 specific measures that enhanced the service during the pandemic, and created a model that offered safe and relevant support for older people while safely adhering to the health and safety recommendations at the time. They provided socially distanced visits, increased phone contact, provided additional information and other supports, helped client to navigate changes to the heath service and systems, organised medication and other supplies for clients.
2. Programme sustainability particularly in relation to funding. AgeWell receive part core funding from the HSE and each year they must source alternative funds from elsewhere to cover the full programme costs. They have been very fortunate to have been supported on their journey since the pilot in 2018 by many different stakeholders including; Social Innovation Fund, Slaintecare, Community Foundation, National Lottery and Meath County Council (through the Capital Enhancement Programme and the Healthy Ireland fund), without whose help they would not have been able to support the 461 older people who have benefited from the service to date.
3. Proving the worth and impact of the programme, and gaining trust and buy in from stakeholders. AgeWell were very fortunate that the HSE and the Director of Nursing saw the potential in AgeWell when they first introduced the programme. Without their backing and promotion of the service AgeWell would not have achieved what they have done to date. They now have data, reports, evaluations, research and publications on the impact of their work, and the benefits that it provides. The AgeWell programme provides peace of mind for family members, secure in the knowledge that their relation has regular companionship at home from someone who will also look out for their health and well-being needs. AgeWell is a win-win for older people. It creates opportunities for active older people to participate in caring roles in their communities that make a difference to the lives of frail, isolated, lonely and vulnerable older people. AgeWell companions are volunteers over the age of 50.

   See Slaintecare Right Care, Right Place, Right Time 2019-2021. The report details the work and impact of AgeWell in East Meath.

   AgeWell Programme as a public health intervention by Prof. Amanda Phelan, Ageing and Community Nursing in the School of Nursing & Midwifery, Trinity College Dublin

   Measuring Older People’s Wellbeing Against a Covid-19 backdrop – by Aidan Manahan
   This data analytical report provided evidence on how Covid-19 affected the wellbeing of AgeWell clients.

3 Outcomes / Benefits

1. Develop and roll out a programme that has successfully supported 461 older people to live well for longer in their own homes and communities, keeping them connected to community life, reducing isolation and loneliness while engaging other older people as active citizens supporting peers who are isolated, frail, vulnerable, at-risk and in-need.
2. AgeWell has achieved significant improvements in the health and wellbeing of older people involved in the programme. AgeWell evaluates its programme at regular intervals to measure service impact. Latest statistics show a 55% reduction in loneliness (ULCA Loneliness scale) of clients since enrolment, 36% relative improvement in wellbeing scores (WHO-5), 17% increase in social and emotional support (MOSS8), 10% improvement in self-rated health, the physical activity levels of client has improved throughout the course of the project, with 85% of clients reporting that they are more active than their peers. 99% of clients were satisfied with the programme, 85% very satisfied. 88% of clients said they would recommend the programme to a friend.
3. AgeWell complements existing services and supports for older people. AgeWell helps to streamline primary care services and reach those in need of services earlier. AgeWell is a programme that integrates with many agencies and organisations. The programme compliments and enhances existing supports and care models and is often the conduit for linking support services for clients. They regularly receive referrals from PCT’s, PHN’s, GP’s, OT’s, and community groups and services.
   AgeWell research shows that the AgeWell programme has saved both clients and the state substantially in terms of avoided hospital, acute care and nursing admissions.