Delivering Better Outcomes – Helping Older People to Help

Themselves

Tony Homer – Associate, Joint Improvement Team

Outcomes approach to community care

Outcomes FrameworkCommunity care users

feeling safe

Users and carers satisfied with their involvement in the

design of care package

Users satisfied with opportunities for social

interaction

User assessments completed to national standard

Carers assessments completed to national standard

Care plans reviewed within agreed timescale

Shift in balance of care from institutional to ‘home

based’ care

People 65+ with intensive needs receiving care at

home

People 65+ receiving personal care at home

Emergency bed days in acute specialties for

people 65+

People 65+ admitted as an emergency twice or

more to acute specialties

People 65+ admitted twice or more as an

emergency who have not had an assessment

Patients waiting in short stay settings, or for more than 6

weeks elsewhere for discharge to appropriate setting

People waiting longer than target for assessment

People waiting longer than target time for service

carers who feel supported and capable to continue in

their role as carer

Access

Carers

Experience

Balance of Care

Risk of Admission

Quality Assessment

Outcomes Framework

Outcomes approach to community care

Talking Points– core concepts

Understand outcomes as the impact or end result of service(s) on a person’s life

The user or carer is involved in identifying desired outcomes = setting goals in partnership with services

Partnership is key – users, carers, services, other

community resources – to delivering outcomes

Quality of life Process Change

Feeling safe

Having things to do

Seeing people

As well as can be

Life as want (including where you live)

Listened to

Having a say

Respect

Responded to

Reliability

Improved confidence

Improved skills

Improved mobility

Reduced symptoms

Carer defined outcomes Quality of life for cared for person

Quality of life of carer

Coping with caring

Process

Quality of life for cared for person

Health and wellbeingA life of their ownPositive relationship with person cared for Freedom from financial hardship

Choices in caring including limitsFeeling informed/skilled/equippedSatisfaction in caringPartnership with services

Valued/respectedHaving a say in servicesResponsive to changing needsMeaningful relationship with practitionersAccessible and available and free at the point of need

Grappling with the Service Change Agenda

Cross-cutting policy priorities

> Personalisation

> Self Directed Support

> Telehealthcare

> Safety

> Information systems

> Service integration

Service Clusters

> Communities and informal networks

> Long term conditions

> Crisis care and interim support

> Housing and care options

Communities and informal care

> Supporting informal carers and volunteer networks> Community capacity buildingBy:> Better understanding the size, profile and needs of the

informal carer population> Taking a non specialist perspective on what resources

look like – not overlooking universal public services> Involving all sections of the community so that they feel

included and recognising that they have a contribution to make

> Investing in the potential of the current community

Communities and informal care – South Ayrshire> Community development approach adopted across

regeneration, health and children’s services. Now also incorporating Older People’s services

> Model based upon Asset Based Communities approach> Focussing upon Girvan, a small costal town/hinterland with

regeneration funding and a new community hospital> Care home re-provisioning with ECH being planned> GIRFEC strategy included in developing agenda for

change – recognising everyone’s place in the community

Long Term Conditions

> Long term care collaborative

> Supporting better self care

> Shifting investment upstream into anticipatory and preventative care

> Telehealthcare

> Using a re-ablement approach to re-skill and re-motivate users rather then create dependency

A Planned Approach to Patients at High Risk of Re-admission to Hospital – Ayrshire & Arran

> Use of SPARRA data to predict highest risk patients

> Quarterly review of highest risk patients

> Encourage use of self-management plans – GPs and DNTs

> Review of all emergency admissions – A&E and Acute

> Notification to NHS 24 and ADOC

> Consideration of pulmonary rehabilitation

Crisis care and interim support

> Avoiding unplanned hospital admissions and readmissions> Avoiding delayed hospital discharges

By:> Appropriate rapid response> 24/7 cover> Intermediate care in a variety of settings> Telehealthcare> Respite support for carers

Crisis Care – Community based intermediate care service - Orkney

Accommodation and care options

> Demographic impacts and housing> Housing quality and accessibility> Owner occupation and the social rented sector> Care HomesAspects of the way forward:> Investment in normal housing> Practical services to support householders> The challenge of cross-tenure initiatives> Specialist housing> New roles for care homes

Accommodation and care options – Scottish Borders> Small rural town with dispersed hinterland population> Long term care home for people with degenerative conditions> Move to tenanted flats with onsite care and support in community> Re-ablement and re-skilling approach – reduced dependency> Social, activity and community engagement support> Shift involved access to state benefits – managing their own

money> Gradual introduction of ILF applications/funding and shift of

purchasing control to users> Adjustments to core provider budget and use of PAs

Things to remember

What would help us to help ourselves?> Easy access to good information> Choice - real options that address your own circumstances> Control over deciding upon your preferred package /

pathway> Self managed or actively involved in service

planning/delivery decisions> Able to decide what opportunities and potential risks are

okay for you> Within a supportive process that is driven by what works

for you