ICF Anticipatory Care Workstream

Paul Adams Head of Primary Care & Community Services

NW Locality, Glasgow HSCP & Workstream Lead for Anticipatory Care

“It pays to plan ahead. It wasn't raining when Noah built the ark.” Anon

“Let o

ur advance w

orrying become

advance thinking and planning”

Winston C

hurchill

ICF Anticipatory Care Workstream(8 Projects)

“Proactive Care”

7. Managed Medication(acute Interface)•Capture need in AC plan•Ensure good medicine management (avoid illness and admission)•Identify people in hospital and promote medicine support on discharge•Raise awareness in acute sites

8. Fast Track Palliative Care Service

• Improve quality of life (and death)• Support choice/preferred place of

death• Avoid hospital admission and

reduce bed delays• Use Personal /AC Plan (“my

thinking ahead”

1. AC Framework Model•Create recognised personal plan•Use standard “Glasgow” approach•Empower patient/clients•Raise staff awareness •Share information•Connect services•Prevent admission

2. SPoA/Admin•Improve access to nursing care•Improve response times•Free Practitioner time to enable proactive AC

3. Glasgow Falls Model

•Create AC Plan•Earlier intervention/rehab•Identification of associated issues (eg equipment/housing)•Reduce risk of further falls/admission to hospital•Advice Exercise, Self Management

4. Community Respiratory Service•Create AC Plan•Improve self-management for people with COPD•Refine care pathways across primary/secondary care•Provide fast response to avoid admission•Supported discharge (shortened stay in hospital)•Share information•Signpost to other services

5. Dementia P.D.S•Create Personal/AC Plan•Establish preferred approach•Provide consistent approach•Provide training/awareness•Improve quality of life•Reduce time in hospital•Signpost•Support person and carer

6. Dementia Strategy•Develop vision for Glasgow•Ensure consistent approach•Ensure clear/consistent information

Success to Date• Effective partnership working, e.g. with Marie Curie, Alzheimers Scotland, Cordia

Home Care.

• Glasgow Palliative Care Fast Track Service available across the city from October with potential to support almost 500 patients at home this year; avoiding around 15,000 bed days in hospital

• Glasgow Dementia Strategy out for consultation with an expectation of complete strategy document and launch Jan/Feb 2016

• Dementia Post Diagnostic Support (PDS) evaluation will complete at end of 2015 and will inform Glasgow’s future approach.

• Respiratory Service will cover all Glasgow by December & expects to receive around 75-100 referrals/month. Of these, 40% will be Urgent, 40% early discharge and 20% supported self-management. 95% of urgent/”at risk of admission” will be seen within 24 hours.

• Existing Falls response pathways have been reviewed and a screening form tested.

Good Practice• Emergence of AC plans across projects

• Sharing learning at local and national events

• Awareness raising of managed medication in acute hospitals.

• Application of evidence-based interventions.

• Utilising technology to release practitioner time which will be focussed on engaging in anticipatory care discussions and personal planning.

• Working with Evaluation Support Scotland to ensure 3rd sector contribution is visible.

Challenges• SPoA infrastructure delays - testing from early 2016

• Recruitment timescales

• New hospital (work with managed medicines)

• Keeping focus (e.g. clarity about what care groups/professions need to be testing/adopting ACPs then gradually roll out).

• Sharing information across multiple platforms

• Finance & sustainability

Service extracts – Fast Track

Service extracts – Respiratory

1.0 WTE Band 7 Team LeadTeam Lead 6.0 WTE Band 6 PhysiotherapistsPhysiotherapists1.0 WTE Band 5 Physiotherapist –rot.Physiotherapist –rot.3.0 WTE Band 6 Respiratory NursesRespiratory Nurses1.4 WTE Band 7 PharmacistPharmacist1.0 WTE Band 6 Occupational Therapist Occupational Therapist 0.5 WTE Band 5 Occupational TherapistOccupational Therapist1.0 WTE Band 6 Dietician Dietician 1.5 WTE Band 3 RehabRehab Support WorkerSupport Worker 1.0 WTE Band 3 Team SecretaryTeam Secretary½ day fortnightly½ day fortnightly Respiratory Consultant (Acute) Respiratory Consultant (Acute)Total over 20 peopleTotal over 20 people

URL: www.alzscot.org/campaigns/glasgow_city_dementia_strategy

“Organizing is what you do before you do something, so that when you do it, it is not all mixed up.” A.A. Milne