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Caring for older adults and family carers, together.
A dyadic integrated care model for older adults living with multimorbidity or frailty and their family carers.
How can integrated care be designed around the needs of both older adults and their family carers?
Recognising family carers as partners in care also means recognising their own needs for support.
Geriatric care takes a comprehensive view of the older person’s health, function and everyday life. Family carers are often central to this care, helping with daily activities, treatment decisions and navigating services. Their own health, priorities and choices also need a clear place in assessment, care planning and ongoing support.
For older adults living with multimorbidity or frailty and their family carers, changes in one person’s circumstances can reshape life for both. Their needs are connected, but their preferences may differ. A care plan therefore needs to consider what matters to each person, what each can and wishes to do, and what support is available beyond the family.
DuoCare explores how their individual and interconnected needs can be addressed together within routine care. Through co-design with older adults, family carers and professionals, we are developing an integrated care model that links geriatric care, carer support, long-term care and community resources.
Rethinking the unit of care
Rethinking the unit of care
DuoCare takes the older person–family carer dyad as a unit of care, while recognising each person’s own needs, priorities and choices. This means understanding both people individually, how their lives and care needs affect one another, and how services can support them together.
The model brings together three perspectives:
The older person
What matters to them: their health, function, everyday life, and the care and support they need.
The family carer
What matters to them: their own health and wellbeing, their experience of caring, and the support they need, including what they feel able and willing to take on.
The care system
How healthcare, long-term care and community resources can work together to respond to both people’s needs and share responsibility for care with families.
These perspectives inform a coordinated care pathway that draws on each person’s strengths, makes room for differing priorities, and connects them with appropriate support. The aim is to make care workable for both, with attention to their relationship and the lives each wishes to lead.
How we are developing DuoCare
How we are developing DuoCare
01 Understand
01 Understand
We begin by listening to older adults and family carers.
Through qualitative interviews and dyadic personas, we examine how families experience multimorbidity, frailty, caregiving, service navigation and transitions between healthcare, long-term care and home.
The aim is to understand not only unmet needs, but also family strengths, preferences, relationships and the different ways families organise care.
02 Co-design
02 Co-design
DuoCare is being developed with, rather than simply for, the people who will use it.
Family carers, healthcare professionals and long-term care professionals take part in co-design workshops to identify key problems, examine existing care pathways and develop practical ways of responding to the needs of the dyad.
03 Build
03 Build
Insights from interviews and co-design are translated into a workable care model.
This includes exploring how dyadic needs can be identified, how care priorities can be discussed, how appropriate support can be offered, and how healthcare and long-term care services can be better connected.
04 Test
04 Test
The emerging model is being tested in real-world clinical settings.
Evaluation focuses not only on potential outcomes for older adults and family carers, but also on whether DuoCare is acceptable, appropriate and feasible for the people who receive and deliver it.
What this work is producing
What this work is producing
We are developing a set of research-informed resources to understand older adults and family caregivers together, translate their experiences into service design, and support the delivery and evaluation of the DuoCare model.
Dyadic personas
Dyadic personas
Understanding two people, and the relationship between them.
Research-informed profiles bring together the perspectives of older adults and family caregivers: what matters to each person, the strengths they draw on, and the challenges they face. These personas explore how their needs and priorities interact, including where they differ, to guide care that recognises both people.
Care journey maps
Care journey maps
Seeing how care unfolds in everyday life.
Journey maps trace how older adults and family caregivers navigate care across home, hospital, and community settings. They make visible the work involved in seeking support, managing transitions, and coordinating services. This highlights gaps in support, and opportunities for better connections.
Co-design insights
Co-design insights
Turning lived experience into design decisions
Conversations and workshops with family caregivers, and practitioners inform the design of DuoCare. Emerging insights are translated into design principles, service priorities, and prototypes, with attention to what people value and what can work in everyday practice.
The DuoCare model
The DuoCare model
Bringing the co-design insights together in a practical model of care.
DuoCare is a dyadic integrated care model for older adults living with multimorbidity and/or frailty and their family caregivers. It brings both perspectives into assessment, care planning, and ongoing support, while recognising each person’s priorities, choices, and wellbeing.
Watch the DuoCare video →
Service blueprints
Service blueprints
mapping the care experience alongside staff roles, workflows, and coordination across services.
Practice and evaluation toolkits
Practice and evaluation toolkits
Workflow, evaluation tools and a structured research database supporting consistent data collection to examine care experiences, outcomes for both members of the dyad, and the feasibility of delivering the model.
Where this work is going
Where this work is going
DuoCare is being developed as a longer-term programme.
The current phase focuses on understanding needs and developing a feasible model of dyadic integrated care.
The next stage will examine whether DuoCare can improve outcomes for family caregivers and older adults compared with usual care, while also studying how the model can be embedded within routine clinical practice.
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