Integrated Care Matters Webinars Series 8: Care Closer to Home

Integrated Care Matters Webinars Series 8: Care Closer to Home


11/10/2023 - 19/06/2024    
All Day

Event Type

IFIC Scotland and partners are delighted to announce the first webinar in our Integrated Care Matters Series 8. This series will consider acute hospital care can be a complex and potentially harmful experience for people with complex care and support needs. Multiple ward moves increase the risk of delirium and deconditioning, prolong length of hospital stay and reduce the likelihood of return home.
Many people express a preference for care at home, or closer to home. To achieve this, we need to join up proactive, personalised chronic care and support with emerging models of urgent community response, ambulatory care, intermediate care and palliative care.

This series explores how we integrate care across these Touchpoints

Join us @IFICInfo #IFICScotland for #IntegratedCareMatters8

Optimising flow to deliver early Comprehensive Geriatric Assessment (CGA) by a multidisciplinary team skilled in managing frailty is highly cost-effective. Proactive acute care enables safe and timely transfer of care closer to home.

  • How can hospital flow and pathways be more attuned to the needs of older people?
  • Who can provide early CGA to achieve better outcomes?
  • What skills and competencies are required?

Download Topic Resource


Prof Anne Hendry
Senior Associate,
International Foundation for Integrated Care (IFIC)
IFIC Scotland

Download Opening Slides


Tom Downes
Consultant Physician and Geriatrician,
Clinical Lead
Quality Improvement
Sheffield Teaching Hospitals NHS Foundation Trust

Tom is also Vice President Clinical Quality, British Geriatrics Society
Health Foundation / Institute for Healthcare Improvement QI Fellow
Tom’s clinical work involves leading rapid multidisciplinary assessment, treatment and supported discharge of older patients with frailty, especially those with complex combinations of medical, social and mental health problems. The Sheffield Service Improvement team has developed Flow Coaching Academies to equip staff at all levels to make sustained improvements to health and care outcomes, experience and cost-effectiveness. This can be applied at a pathway, organisation or whole system level. Tom led the introduction of a ‘Discharge to Assess’ approach to support earlier return home with support to optimise independence.

Mark Young
Advanced Clinical Practitioner – Frailty
Manx Care

Mark is a physiotherapist but his current role spans frailty across the healthcare system on the Isle of Man. He has been involved in establishing a frailty unit and creating a pathway for patients with frailty admitted to Noble’s hospital, supporting Care Home MDT’s and proactive reviews, establishing frailty clinics within GP practices, and a “bone-health” ward round in the Ortho-geriatric service.

Having grown up in Australia, Mariem moved to her father’s homeland in the Middle East where she worked with refugees and survivors of violence. This inspired her ongoing commitment to promoting stories that strengthen the voice for equality. Her next move was to her mother’s homeland – Scotland – where she has been working closely with ethnically diverse communities to explore issues often considered taboo. This has led to the creation of her socially engaged theatre and projects including If I Had A Girl…, One Mississippi, and A Knot A Day, that explore issues such as migration and displacement, honour violence, and mental health. Her writing also spans essays and creative non-fiction, and she continues to work internationally training Women Human Rights Defenders in the Middle East and North Africa. Her latest play, Revolution Days, is about her experiences as an Aid Worker and was showcased in 2021; and her audio piece, The Jinn in Me, about Jinn beliefs and their impact on mental health was broadcast on BBC platforms in 2021.

Frances Campbell and Agnes Wells,
Specialist Acute Care for the Elderly (ACE)
Nurse Practitioners
NHS Lanarkshire

Frances and Agnes work at University Hospital Monklands to support holistic assessment, care planning and discharge planning, liaising with ward MDTs, patients, families and support networks. Their experience, and passion in caring for older people and advanced clinical skills allow them to assess, prescribe and implement treatments to enhance the journey through acute care and transition home.

Proactive care identifies and targets people at risk of poor health and social outcomes and provides coordinated and tailored support to help them stay well. Individuals at risk of poor outcomes are identified using screening tools combined with professional judgement. Those with significant or escalating risk are offered a comprehensive multi-disciplinary assessment and appropriate interventions co-ordinated by a local multidisciplinary team of healthcare, social care and community or voluntary service partners working together. The older person and their carer or family will be involved in developing a personalised care plan based on their goals and preferences. Emerging evidence shows that the approach can improve care continuity and coordination and reduce emergency attendances, particularly if it is supported by rapid access to alternatives to acute care closer to home.

Download Topic Resource

Download Flash Report


Prof Anne Hendry
Senior Associate,
International Foundation for Integrated Care (IFIC)
IFIC Scotland


Dr. Mohamed A. Salem
Resident Specialist in Geriatric Medicine
Board member/ treasurer – Geriatric Medicine Society of Malta
Coordinator – Frailty Working Group, Malta

A Maltese citizen, Mohamed graduated from Cairo University in Egypt. He previously worked in primary care in Malta and took part in a number of European programmes including the European Platform of Rehabilitation and trained as an auditor for the European quality in social services programme(EQUASS). He joined the Medical training programme in Mater Dei Hospital Malta in 2013 then the department of Geriatric Medicine in 2016. From 2018 he supported the European Joint Action on Frailty and established the Maltese Frailty working group, becoming the secretary of the group in 2019. Mohamed completed his higher specialist training in geriatric medicine and has been a Board member/treasurer of the Malta geriatric medicine society since March 2019. With colleagues from Saint Vincent de Paul long term care facility he established a multidisciplinary frailty hub for assessment and early intervention of older people in the community considered to have frailty.

Download Mohamed Salem’s Presentation

Dr Miquel Angel Mas
Consultant Geriatrician
Hospital Universitari Germans Trias i Pujol
Badalona, Catalonia

Miquel works in the Institut Català de la Salut as member of the Metropolitana Nord Chronic Care Management Team and is a member of the Geriatric Division at Hospital Universitari Germans Trias i Pujol.
His ongoing projects include the development of integrated care strategies at meso level tailored to people with multiple chronic conditions and advanced illness, in the North Barcelona metropolitan area. He has expertise on innovating in the provision of community-based care for health crises management in the community for vulnerable older populations and has presented several communications on this topic.

Lucy Lewis
Consultant Practitioner,
Wiltshire Health and Care, England

Lucy Lewis is a Consultant Practitioner, Nurse by profession specialising in older people and frailty. She clinically leads South Wiltshire NHS@Home, sits on her Integrated Care Board Clinical Operations group and represents the system in the NHSE South-West Clinical leads Improvement group for NHS@Home. Following completion of her MSc in Advanced Clinical Practice, Lucy undertook the Health Education England Frailty Quality Improvement fellowship before becoming a Trainee Consultant on the HEE South-East Consultant Practitioner Development Programme. Lucy is undertaking a part time PhD focusing on How older Individuals & clinicians make decisions about cancer treatment and Support (The CHOICES study). She has represented Nurses and AHPs (NAHP) on the British Geriatrics Society Policy & Communications committee and now sits on the BGS Frailty & Urgent Care Special Interest Group committee having been the BGS NAHP council chair from 2019-2021. Lucy completed a Florence Nightingale Foundation scholarship in 2019 and is a FNF Alumni Champion. Her scholarship took her first to Scotland where she explored examples of government supported initiatives which actively sought to improve integrated pathways for older people and those living with frailty. In Canada, she spent time in Dalhousie, Nova Scotia with Professor Ken Rockwood, his research team and the Canadian Frailty Network. In Toronto she met the Onco-geriatrics clinic team and the research team at University of Toronto. This increased the depth and breadth of her PhD research and began a fruitful collaboration with international colleagues.

Integrated care for older people with frailty has a growing evidence base. Many countries are adopting new models of specialist multidisciplinary assessment, care and support in the community to improve continuity and coordination of care and enable older people to maintain their functional ability and independence for as long as possible. This webinar continues the theme of proactive and integrated comprehensive geriatric assessment in the community.

We will hear examples of assessment and targeted interventions co-ordinated by multidisciplinary teams of healthcare, social care, community and voluntary service partners working together in communities in North Lanarkshire, Scotland and in Cork and Kerry in the Republic of Ireland. Presenters will describe how the older person and their carer or family are involved in developing a personalised care plan based on their goals and preferences, and how professionals provide case management support across the interface between care settings and services.


Prof Anne Hendry
Senior Associate,
International Foundation for Integrated Care (IFIC)
IFIC Scotland


Ana Talbot
Consultant in Older Adult Medicine, NHS Lanarkshire
West of Scotland Innovation Fellow
Honorary Senior Clinical Lecturer, University of Glasgow

Ana completed undergraduate and early postgraduate training in Ireland and has been working in the West of Scotland for over 20 years. Based in North Lanarkshire at University Hospital Monklands, she has an interest in person centred care, self management, realistic medicine and innovation in frailty. During her career she has been involved in setting up telemedicine delivered thrombolysis for stroke, hospital at home and is now leading the development of community MDT meetings in primary care and nursing homes for older people with frailty. She is in the first cohort of NHS Scotland’s Innovation Fellows.

Finola Cronin
Operational Lead, ICPOP Hub, Cork-South City & West Cork, St Finbarr’s Hospital


Kathleen O Donoghue
Operational Lead, Kerry Integrated Care Programme for Older Persons


Bart Daly
Consultant Geriatrician


In association with:   uws-logo    

Webinar Lead:

Professor Anne Hendry
Director of IFIC Scotland
Twitter Link@AnneIFICScot