Creative Local Action, Responses and Engagement (CLARE) - Models of care and support

CLARE’s key objective is to empower older people to maintain their independence and reduce feelings of isolation and loneliness. The model adopts a strengths-based approach, valuing the assets of the individual and the community that they live in. Co-production is central to the work of CLARE. It supports innovative thinking, ensuring that it is user-led and not service-led, working in partnership with the older person and their community.

Each older person referred meets with the CLARE Community Social Worker to engage in an initial guided conversation in which they are viewed as expert in their experience and in identifying what actions and supports will work for them. CLARE delivers its services with a mix of staff and volunteers known as Community Champion volunteers. Support includes connecting older people to health and social support services and community resources, practical assistance based on individual needs (such as accompanying older people to the bank, shops or activities) and purposeful befriending.

CLARE works closely with the Public Health Agency and Belfast Health and Social Care Trust. The service will take referrals from a wide range of sources including self-referrals.

Current users and outcomes

In 2017, CLARE:

Estimated financial benefits

As a community-based early intervention model, CLARE helps to ensure older people can remain in their community for longer with personalised, effective support. This has the potential to result in savings in terms of reduced hospital and nursing home admissions and better uptake of health care appointments. CLARE is keen to find evaluation partners to measure cost avoidance and savings.

Potential benefits

Barriers and enablers for expansion

CLARE wants to contribute to systemic change in the way health and social care is designed by working with older people, their communities and the organisations involved in the commissioning and delivery of services. CLARE is currently talking with isolated older people whose opinions are not usually heard in other areas of Belfast, identifying what support they want to improve wellbeing and whether CLARE could help. Any expansion of CLARE requires extensive community consultations and endorsement as well as partnership working. CLARE is keen to share the model and learning but this will not lead to a simple scaling up or replication as each community must consider how it can dovetail with and add value to their existing assets.


CLARE is a member of Belfast City Council Healthy Ageing Strategic Partnership where voluntary and community and statutory organisations can share information and coordinate approaches to tackling loneliness and improving wellbeing for older people. CLARE is also a member of the Social Work Strategy Local Engagement Partnership for co-production and Belfast Health and Social Care Self-Directed Support Implementation Group.

Case Study: CLARE


Freda is 94 years old, lives on her own and had become lonelier in recent years. She copes with a range of medical conditions – a stroke, glaucoma, arthritis, occasional falls and memory problems. She was also finding it hard to attend medical appointments and access her money and pay bills at the local bank because of the impact of decreased mobility, visual impairment and memory problems.

Support provided

CLARE has provided person-centred support tailored to Freda’s needs including help with accessing Direct Payments which has enabled her to get out to more activities with the help of a personal assistant. She has also been assisted to access support from a range of health professionals through CLARE staff and volunteers.


Greater independence and support to live at home by enabling real connections to health and social care support and the assets of CLARE volunteers in her local community.

Community-based models (SCIE Highlights No 6)
Previous section | All sections | Next section