2.2 · web viewinterventions monitored through daily huddle; no formal / traditional ‘referral’...

2.2 Improving outcomes for people, including those with a caring role, as their needs change by:

2.2.1 fully integrated Multi-Disciplinary Teams (MDTs) with integrated line management and appropriate professional governance arrangements, adopting a ‘One Team’1 approach to offer seamless care

Example of Good Practice - Rural

Enablers High Impact Proposals OutcomesLive in good health for longer

Leadership Assets Based Integrated Teams SPOC Live independently at homeAccountability Positive experience of health and social careVision Self Management Aligned to GP Practice ACP Improve quality of lifeRelationships Reduce inequalitiesCulture Connected Aligned with Acute Care Reablement Carers are supportedTeam Ethos Safe from harmGovernance Live Independently Enhanced Residential Care Intermediate Care Staff engaged and supported

Effi cient and effective

Aberdeenshire Health and Social Care Partnership established a multi-disciplinary Virtual Community Ward service to proactively identify individuals who are likely to need enhanced care and support and to agree how they will support these needs through:

Additional, short-term homecare; Additional nursing support; Focused holistic support planning, including medical care planning Quick access to Allied Health Professionals and delivery of aids and

equipment The Virtual Community Ward Teams meet, as a norm, daily within the GP Practice for a short face-to-face huddle which is led by the GP. Within these huddles:

Intelligence of vulnerable patients shared freely between disciplines; Interventions agreed by team recorded on GP system and appropriate

professional takes responsibility for action; Interventions monitored through daily huddle;

No formal / traditional ‘referral’ required between team members

During the first 36 months of operation, 4,685 people have been admitted to the Virtual Community Ward, with 1,640 hospital admissions avoided and 33 Care Home placements avoided or delayed.

1 Work is underway with the Office of the Chief Nursing Officer, the Office of the Chief Social Work Adviser and the Primary Care Division to develop guidance on the development of the ‘One Team’ Concept

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Example of Good Practice – Urban




In seeking to better support people with mild to moderate mental health problems, West Lothian Health and Social Care Partnership have designed integrated Community Wellbeing Hubs. These Hubs will integrate the provision of Primary, Secondary and Third Sector service provision, acting as a front door to mental health services for people requiring support and a focal point for future pathway development based on identified gaps in service provision.

Primarily led by Community Link Workers, offering an early intervention approach and signposting to Third Sector and community supports, people will also be able to draw on more specialist support such as Occupational Therapy, Community Mental Health Nurses and Psychologists where their needs require this. With a clear focus on the needs and preferences of the person, the service will: Focus on the patient’s problems are whatever the patient says they are; Be patient-centred and aim to meet the needs of the patient (patient’s

criteria) rather than the patient having to fit the service’s criteria; Offer less assessment and more support; Respond flexibly to patient’s needs and preferences – with seamless care,

not silo working promoted across all staff groups; and Recognise the patient as a patient of the whole service, with no need for

formal internal referrals.

The anticipated benefit of this service is not only improved outcomes for people with reduced medicalisation of mental health conditions, but also an anticipated net cost avoidance of almost £400,000 per annum.

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Example of Good Practice – City




Aberdeen City Health and Social Care Partnership, together with the Housing Team from Aberdeen City Council and partners from Bon Accord Care have piloted an Interim Housing Model to support people return home after a hospital stay.

This pilot centred on two properties that were adapted to meet the needs of a wide range of people who required additional support when medically fit for discharge from hospital, while offering the time and dedicated input required to fully determine their longer-term needs.

Social Work, Housing and Occupational Therapy colleagues worked jointly to support 5 people through these properties in the first 8 months of operation, achieving 82% occupancy and a reduction of 321 bed days that would otherwise have been recorded as delayed discharges.

From a financial perspective, estimated cost avoided in the first 8 months of operation equated to almost double the annual running cost of this service. Aberdeen City Health and Social Care Partnership will pilot this service further to determine whether it should be delivered at scale.

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2.2.2 MDTs aligned to GP Practices to provide targeted support for those with greatest need and an early, concerted response when a member of the team identifies a ‘trigger’ that something may have changed in a person’s life and / or condition

Example of Good Practice – Rural




In the Clydesdale area of South Lanarkshire, the Health and Social Care Partnership have introduced an Advanced Nurse Practitioner led Urgent Care Home Visiting service in line with the 2018 GMS Contract for Scotland and associated Memorandum of Understanding.

Established on 08 April 2019, this service has seen a significant reduction in the percentage of people admitted and in those receiving continued treatment, with an associated increase in the percentage of people discharged from the service, with or without a prescription.

By 17 May 2019, the Advanced Nurse Practitioner service had provided urgent home visits to 234 people. This equates to 92% of all home visits and has saved 142 hours of GP time.

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Example of Good Practice – Urban




The East Kilbride Locality Response Service has been developed by South Lanarkshire Health and Social Care Partnership and the local GP Teams to create an integrated clinical and care support arrangement for those at greatest risk of hospital admission.

This service pulls together the resources available in a community setting from General Practice, District Nursing, Social Work, Care at Home, Allied Health Professions, Residential Care Staff and Day Service Teams to mobilise and respond to a person’s changing needs.

In doing so, the emphasis is on reconfiguring existing mainstream services to accommodate the scaling up and down of the care required as required by ensuring, wherever possible, that the service is provided by the same practitioner/team. As a result, all services collaborate and respond timeously in the spirit of early intervention and prevention/asset based approaches, to support people in community settings.

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Example of Good Practice - City




Edinburgh Health and Social Care Partnership embedded Practice Mental Health Nurses (PMHN) within 12 GP Practices to work collaboratively with other healthcare professionals, agencies and third sector care providers as well as act as a contact point and liaise with practice health care professionals for patients with complex mental health problems.

In doing so, the Nurses applied a holistic approach to help manage people with mental health issues presenting to GPs including those with mild-moderate depression, anxiety, panic disorders, stress, insomnia, emotional distress, bereavement, alcohol and drug misuse.

An analysis of impact demonstrated that the Nurses offered an equivalent capacity injection of 4 – 5 GP sessions per week, with the majority of Practices experiencing a reduction in referrals to secondary care Adult Mental Health services, including one which experienced a 48% reduction.

Further, an analysis of individuals with complex needs within one practice saw a 74% reduction in Accident and Emergency, Unscheduled Care presentations and inpatient admissions.

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2.2.3 expert Nursing and Consultant advice within MDTs and by those teams during any hospital stay to improve continuity of care and support and reduce avoidable admissions and length of stay

Example of Good Practice – Building Care Home Capability




South Lanarkshire Health and Social Care Partnership have worked with two Care Homes to develop and trial a Continence Promotion Care Bundle improve the capability of Care Home staff in effectively supporting people to manage their continence.

Supported by a two day training programme for Care Home staff, the bundle process measures include whether:

There is a documented assessment detailing the type of continence; Toileting assistance and daily episodes of incontinence are

documented; Fluid intake and output have been recorded daily; The resident has agreed to reduce caffeine intake; and Medication has been reviewed in the last month.

In month 8 100% compliance with the bundle measures was achieved, with performance sustained at or slightly below that level for the remainder of the reporting period. The corresponding results demonstrated:

65% reduction in falls; 50% reduction in UTI; 40% reduction in hospital admission for falls or UTI; and 30% reduction in skin damage.

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Example of Good Practice – Supplementing Care Home Capacity




The Care Home Liaison Nursing Service introduced by Inverclyde Health and Social Care Partnership is designed to deliver more effective use of nursing and wider primary care inputs to support residents and nurses in care homes.

Through close working with individuals, families, staff and carers, the service offers anticipatory prescribing, and future care planning as well as Palliative and End of Life Care with the aim of supporting people to remain in their care setting.

The Liaison service actively supports 45 residents each month, over and above those supported through the core District Nursing service. Despite seeing an increase of almost 20% in the admission to long term care in 2018/19, there has been a reduction in the number of attendances at the Emergency Department and admissions to acute care during the corresponding period.

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Example of Good Practice – Teleconference Support




Perth and Kinross Health and Social Care Partnership has invested in trialling Attend Anywhere to offer more specialist care and support planning for individuals in Care Homes and those accommodated within HMP Perth.

It is anticipated that this will offer a less disruptive method of securing specialist healthcare input to the care and support planning process for individuals, reducing their personal need to travel and easing the associated pressures on Care Home and Prison services.

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Example of Good Practice – Trusted Assessor Approach




Through a joint review of issues affecting the delivery of support within Care Homes, Aberdeen City Health and Social Care Partnership and the local Care Home Forum identified variations in the hospital discharge process.

Linked to this, Members of the Care Home Forum highlighted the increasing pressures they were experiencing and the higher levels of support they were providing to residents with complex needs, thereby adversely affecting the staffing levels available to link with acute care.

Recognising that these factors were leading to delays in admission to Care Homes and, hence discharges from hospital, it was agreed to test a ‘Trusted Assessor’ model that would see someone linking with Acute Care on behalf of and with the permission of the provider to undertake assessments.

This model originates from Lincolnshire where the Trusted Assessor works within Acute Care with full access to patient systems and the social work team to plan discharge.

Aberdeen City Health and Social Care Partnership anticipate that this will result in:

People having an improved experience of discharge from hospital to a care home;

Care home staff being freed up to provide care and support to those with complex needs;

Improved bed flow into care homes; and Reduced delays in people being discharged from Acute Care.

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2.2.4 enhanced MDT liaison within care homes, residential settings and supported accommodation, as well as the supported development of staff who work in these settings, to enhance the quality and level of care and support available

Example of Good Practice – Alternative to Admission




The Dundee Enhanced Community Support Acute Team comprises Medicine for the Elderly Consultant, GPs with Specialist Interest in Medicine for the Elderly, Advanced Nurse Practitioners and Pharmacists. The Team works with wider community-based teams and services to provide specialist assessment, care planning, investigations, and interventions.

On average 20 patients per month have been referred to this service with 70% avoiding admission and being supported within a homely setting.

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Example of Good Practice – Early Intervention in A&E




Moray Health and Social Care Partnership provided Occupational Therapy support in A&E at Dr Gray’s Hospital to offer multi-factorial assessment, establish an integrated falls pathway and reduce unnecessary hospital admissions.

The service operates seven days per week and received on average 50 referrals per month, with 37% having been discharged directly home. This has resulted in an estimated annual cost avoided of £860,000.

Example of Good Practice – Early Supported Discharge




Aberdeen Health and Social Care Partnership introduced the Acute Care at Home service to support early discharge from acute hospital and complete the final elements of the hospital care plan at home.

The Multi-Disciplinary Team comprised Advanced Nurse Practitioner, Occupational Therapist, Physiotherapist, Pharmacy Technician and Healthcare Support Worker capacity.

In the six months to December 2018, 84 people were admitted to the service and at the 90 day point following admission 2.5% more were living at home when compared to those admitted to a Geriatric Assessment Unit and mortality rates were 6.8% lower than the same control group.

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2.2 · web viewinterventions monitored through daily huddle; no formal / traditional ‘referral’...

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