All Inclusive Care for Older People (ALICE) Co-design Project

The Central Coast is home to the largest and fastest growing number of elderly and frail patients in New South Wales. By 2031, more than 22% of older people on the Coast will be aged 70 or over (some 80,000 people). The elderly and frail cohort (>70yrs or >50yrs Aboriginal and Torres Strait Islander people) are at the highest risk of adverse outcomes such as falls, disability, unscheduled hospital admissions, longer stays in hospital, uncontrolled polypharmacy, and greater difficulty recovering from illness and surgery.

To address such problems, the elderly and frail cohort requires multimodal care due that enable them to better engage in prevention and health promotion activities that support them to live as well as possible with their multiple and long-term conditions in the home environment and address key issues related to declining functional capacity and mental health. However, the lack of coordinated access to primary and community-based services (some 35% of people do not have access to a GP on the Coast) as well as community aged care support, combined with increasing numbers of older people living in social isolation and disconnected from the communities in which they live, means that care outcomes for older people are not as good as they should be.

To address this, the ALICE (All Inclusive Care for Older People) project, aims to support people to remain independent and well, and to avoid the need for hospital visits or residential care. We will be working with local communities to create local models of services and community connections that allow older people and their carers to receive support and best-practice care in the community and at home.

The purpose of ALICE is to improve care experience and outcomes for older people living with complex health and social care needs in our Central Coast communities, supporting them to remain independent and well, and delaying or avoiding the use of institutional care. ALICE is designed to build on the Central Coast’s Elderly and Frail Connected Care Pathway approach to create an evidence-based neighbourhood model for integrated community care.

ALICE – Key Features

• A neighbourhood model co-designed with the local community to create an alliance promoting all-inclusive health and social care to older people living with complex health and social care needs
• Rapid access to preventative and co-ordinated health and social care services including neighbourhood-based care and support
• Leveraging partnerships across public, private and the NGO sector in the local community
• Enabled by the latest at-home health and wellbeing technologies
• Monitoring and evaluation framework that supports cycles of quality improvement, ongoing implementation guidance, and evaluation of impact
• Local pathways to support education and training for the next generation of the care workforce
• Sequencing for rapid translation of the model of care to other neighbourhoods
• Transformational and sustainable effect on costs and outcomes of care
• Economic and social benefits to the local community

Crucial to the success of the ALICE model is its ability to ‘scale-deep’ through the process of co-designing and co-creating its neighbourhood-based programs in ways that bring community stakeholders together to form productive alliances.