active and independent living falls programme monthly report … · 07/11/2017 active and...
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Active and Independent Living Falls Programme Monthly Report October 2017
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30 Health & Social Care Partnerships actively participating 25 SAS Area Service Managers /Team Leaders/Specialist Paramedics as Project Champions Supporting Mechanisms • National data distributed to all project leads • Progress Reports from the HSCP/SAS project teams • Monthly Flash Report & topical Webex led by National Team • Ongoing site visits/telephone support by AILP and LWiC to local project teams • National learning sessions (25th November 2016, 31 August 2017) • National works streams including economic modelling and development of
training resources.
SAS Falls & Frailty Pathways Programme
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This specific programme contributes to: Towards 2020: Taking Care to the Patient (Scottish Ambulance)
The Prevention and Management of Falls in the Community: A Framework for Action for Scotland 2014/2016
Health and Social Care Delivery Plan 2016
Primary Care Transformation Plan
Policy Context & Programme Links
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To AHPs Community falls assessment and rehabilitation staff will see
people earlier, when more likely to respond to interventions.
To Primary Care Community rehabilitation staff rather than GPs will arrange,
provide or refer for any further support that is required. For example, physiotherapy and occupational therapy, installation of a personal alarm, home adaptation, eye health checks.
Fewer people will look to General Practice or Emergency Social Care as first point of contact in case of concern or difficulties in the days or weeks following their fall.
To Acute Services
In all areas SAS crews will provide access to multi-factorial falls assessment for all people left at home following a fall. This will reduce likelihood of future falls and A&E attendance.
In many HSCP areas SAS crews will have access to same day community-based alternatives to A&E.
Benefits
Multi-agency leadership and governance to develop,
embed and sustain the pathway.
Local QI knowledge and support to facilitate
improvement.
Engaged, competent and confident frontline work
force with support to take decisions re conveyance.
•Agreement of aims and goals of the pathway. •Application of appropriate improvement methodologies, with QI support when required. •Measurement to understand the system and monitor activity and change.
•Consistent SAS leadership at all levels . •A local multiagency group overseeing the development of the pathway. •Clarity and agreement of roles & responsibilities of contributing partners in the pathway. •A local multiagency group monitoring pathway activity and outcomes (including adverse incidents) and responding to findings.
•Training and information for SAS staff to improve their understanding the aims of the pathway, how it works and the benefits to service users and the system, and to enhance clinical decision making. •Effective communication to SAS staff of the local pathway and parameters. •SAS and community staff understand roles and challenges of others delivering the pathway. •Decision making support, including ehealth and other technology support.
Simple, quick access to integrated community-
based services providing the right support.
Stakeholder engagement including service users and
carers.
•Community coproduction. •Mechanism for service user feedback. •Information about the pathway for the public. •Information provided by SAS at point of care.
•Clarity around consent. •A single point of access 24/7 to integrated community services. •Systems in place to receive, acknowledge, record and respond to referral from SAS. •Rapid telephone triage to ascertain response required. •Co-ordination of the community response including GP involvement. •Services providing an immediate/crisis response - to enable a person to remain in their home or close to home. •Multidisciplinary/ multi-agency services providing a planned response within a defined timescale - to enable recovery, restore independence and prevent further falls.
SAS Falls/Frailty Pathway Driver Diagram
What drives pathway development and implementation?
Key elements (Identified from scoping)
AIM
TO improve the experience and outcomes of people the SAS respond to following a fall and/or with frailty.
BY the SAS providing access to the most appropriate support and care at the time of the response.
THROUGH a simple and coherent pathway . Nationally, by end of October 2017: • the SAS will refer 50% of people aged 65+ they leave at home following a fall to community services for further assessment and support. •there will be a 10% reduction in the conveyance to hospital of uninjured people aged 65+ who have fallen.
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Progress Status by HSCP area
Pathway operational - 26 Pathway agreed - 3 Pathway Planning - 1
Edinburgh City Borders Shetland
East Lothian Stirling & Clacks/Falkirk
Midlothian East Renfrewshire
West Lothian
Aberdeen City
Moray
Aberdeenshire
Western Isles
Orkney
Highland, Argyll & Bute
Dumfries & Galloway
Glasgow City
East Dunbartonshire
West Dunbartonshire
Inverclyde
Renfrewshire
N/S Lanarkshire
Perth & Kinross
Angus
Dundee
Fife
N/S/E Ayrshire
Based on September Progress Reports
Partnerships in bold fully spread
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Project Plan – Milestones – SAS Falls Insert Planned Milestones – Colour green if complete, red if overdue
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Sep17 Oct17 Nov17 Dec17 Jan18 Feb18
ePRF Falls Screen go live JRCALC Guideline on Falls in Older People due for publication Report on economic modelling to Directors Validate integration of SAS attendance data and ISD hospital attendance/ admission data Complete first Test of Change of ePRF to Falls team electronic communication (Lanarkshire) Webex: Sustainability Workshop for SAS project leaders
Complete delivery of Sustainability Plan Falls and Frailty pathways go live on the SAS Pathways App Economic Model framework to be completed (revised date) Complete second Test of Change of ePRF to Falls team electronic communication (Lanarkshire) Webex: Quality Improvement
Interim Report on achievement against national action group improvement aims to AHP Directors SAS Falls Leads learning session. Further deep dive analysis at more HSCP areas – West Lothian, Edinburgh City, Perth, Aberdeen City Forth Valley go-live Fife go-live Webex: Successes and Challenges case studies
Complete analysis of Economic Model by partnership (revised date, SAS / ISD data validation delayed analysis) Recruitment of joint SAS/TEC Programme/AILP post to support joint working, spread and sustainability. Completion of report on SAS Staff Survey (SAS leading) Further deep dive data analysis at more HSCP areas – East Lothian, Forth Valley GGC go live
Monthly: Compile and distribute Flash report to all HSCPs. Run topic centred Webex. National Coordination Team Meeting. 07/11/2017 Active and Independent Living Programme
Further SAS Improvement Leaders workshop Pan- Lothian SAS Falls sustainability meeting. Review Impact across each HSCP area Webex: Economic Model
Determine QI support priority areas based on impact review of HSCPs Support further areas to complete deep dive analysis Webex: topic TBD
Key Performance Indicators
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Code Definition
SAS Falls and Frailty Pathways Project
FallsAccess01 % of Community Referrals following SAS attendance to non-conveyed falls cases
FallsAccess02 # of Community Falls Multi-factorial Assessments
FallsAccess03 % reduction in conveyance to hospital following a fall without injury
Wider programme (in development)
H&W01 – Core: # of people accessing self-management information from identified data sources.
H&W02 – Core % of people reporting benefit from the information received.
PW01 – Core % of people seen by an AHP who are signposted into non health and social care services.
R&I01 – Core # of Falls Technology Initiatives aligned to The Scottish Centre for Telehealth & Telecare
Key Performance Indicator Report Quantitive: FallsAccess01
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Category: ACCESS Improvement Programme Specific Measure Measure: % of Community Referrals following SAS attendance to non-conveyed uninjured faller
Aim: 50% by end October 2017
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Measure Label: FallsAccess01 Data Source: SAS national data and HSCP locally reported referral data. Aim: 50% of all non-dangerous, non-conveyed cases. Issues / Risks: Culture change within SAS crews. Ability of crews to successfully identify suitable cases. Sufficient availability of community services to meet immediate needs. Spread and Sustainability: (where are you doing it now, where do you plan to go).
AILP, HIS and SAS IAs to work to together to build sustainability within local partnerships of SAS team leaders and community rehabilitation services. Comments: Aberdeen City, East Dunbartonshire, Inverclyde, West Lothian making significant progress with referral rates above 20%.
Key Performance Indicator Detail Quantitive: FallsAccess01
Key Performance Indicator Report Quantitive: FallsAccess03
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Category: ACCESS Improvement Programme Specific Measure Measure: % reduction in conveyance to hospital following an uninjured fall
Shifts showing
increased
conveyance rate
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Measure Label: Falls Access 03 Data Source: SAS national data and HSCP locally reported referral data Aim: 10% reduction from 57% to %47
Issues / Risks: Culture change within SAS crews Ability of crews to successfully identify suitable cases
Spread and Sustainability: (where are you doing it now, where do you plan to go).
AILP, HIS and SAS IAs to work to together to build sustainability within local partnerships of SAS team leaders and community rehabilitation services.
Comments: No shift in this measure to date, as crews are not yet familiar with the process of referral to community services. Anticipate that progress on this measure will follow significant success of FallsAccess01.
Significant variation in historic practice across all HSCPs with 40% to 68% of uninjured fallers being conveyed. Existing variation depends upon availability of uninjured pathways, future variation will remain for same reasons.
Key Performance Indicator Report Quantitive: FallsAccess03
Risk Register – SAS Falls & Frailty
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High Lack of commitment from
some HSCPs or local SAS
teams to progress work (7)
Lack of GP buy in
Lack of ongoing
maintenance & monitoring
of pathways (5b)
Loss of project leadership
within HSCPs (5a)
Unable to secure national
data sharing agreement
Crews do not use pathways
due to general reluctance to
change practice or even fear
of repercussions if ‘wrong’
decision made (1)
SAS unable to release staff
for training (2)
Medium Referred cases need to be
admitted
Poor Case Finding (3b)
Lack of focus by senior HSCP
managers (4~)
Patients decline referral
Delays to ePRF
Lack of visible and explicit
support from SAS senior
management (3a)
Low Delays to SAS App Divergence in offer across
HSCPs
SAS divisional restructure (6)
Low Medium High
Impact
Probability
Good News Story
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Edinburgh City Case Study 89 yr old lady fell, SAS attended, ensured lady uninjured and medically well. SAS referred to Edinburgh City Social Care Direct SPOA, which triggered installation of a temporary personal alarm pending further assessment. Subsequent to referral, Community Rehab representative attended patient’s home, conducted a MFA, arranged for patient to commence strength and balance exercises, and arranged for a permanent Community Alarm system to be installed in the home.
Project Plan – Milestones – Wider Falls Insert Planned Milestones – Colour green if complete, red if overdue Falls Leads Network Coordination Group Webex every 6 weeks
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June 17 July17 Aug17 Sep17 Oct17 Nov17
Webinar Presentation (European Innovation Partnership on Active & Healthy Ageing ) Falls Leads Webex
Campaign launch: Take the Balance Challenge Commence review of Up and About booklet and NHS inform falls content. Short film on falls prevention finalised.
Balance Challenge: Talking Heads Interviews and Info-graphic Initial meeting of Falls Prevention Multi-agency Action Group (FPMAG) Commence review of implementation of Framework for Action 2014-16. Interviews for NES Career Fellowship post (to develop Falls Learning Guidance) Falls Leads Webex
Balance Challenge: focus TBD Campaign for H&SC professionals and partner organisations (to coincide with World Older Peoples’ Day) Complete review of implementation of Framework for Action 2014-16. Publication of Consensus Statement by FPMAG AHP NES Fellow in post
Balance Challenge: Targeted Pop Ups (RoSPA) Publication of Scottish Fire and Rescue Safe & Well Policy
Draft Measurement plan, share back to HSCP Falls Leads for comment Workshop for development of falls prevention resources for Scottish Prison Service. Falls Leads Webex
Risk Register – Wider Falls Programme
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High •In sufficient funding for campaign materials. •Poor engagement re Consensus Statement. •NHS health withdraw support of Up and About.
Medium
Low
Low Medium High
Impact
Probability
What help do you need from SG leaders and across the AILP team?
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SAS Falls • Further direct approach to HSCP Chief Officers to refresh commitment and priority. (November)
Wider Falls Programme • Discussion re Falls and Fracture Consensus Statement • Discussion re Primary Care OOH review and response to fallen uninjured • Whole Team assistance with the Balance Challenge opportunity !
Appendices
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Appendix A: National Falls Programme Logic Model Appendix A1: Health & Wellbeing activities Appendix A2: Access activities Appendix A3: Awareness activities Appendix A4: Partnership Working activities Appendix A5: Research & Innovation activities Appendix A6: Workforce & Practice Transformation activities
Falls Programme Logic Model Sept 2016 - Version 1 Scoping Inputs Outputs Outcomes
Situation Ambitions Priorities Resources Activities Short -Term Medium-Term Long-Term
Health & Well-being
Access
Awareness
Partnership Working
Research & Innovation
Workforce & Practice
Transformation
Drive and support the delivery of the Framework for Action 2014-16 Specifically: •Drive and support the implementation of SAS Falls and Frailty Pathways. •Engage and develop the workforce. Co-create a Framework for Action 2017-20
TEAM
Programme Lead (1 WTE)
IA
(0.5 WTE )
Partners/
Suppliers
ADSG
Community Falls Leads
Network
H&SCPs
SAS
LWiC (HIS)
TEC Programm
e
SFRS
BSC
The Alliance
Care Inspectora
te
Scottish Care
Public
3rd Sector
NOS
ISD
NES
NHS 24
Awareness Take the Balance Challenge Campaign, July 2017. Falls awareness week 2017: people working with older people. Falls, Fractures, Frailty & Osteoporosis Conference, May 2017. Publication of Falls and Fracture Consensus Statement, 2017 tbc.
Access
•Work with all H&SCPs, SAS , LWiC, the TEC programme and the Alliance to improve access to falls prevention and management services in the community setting, for older people the SAS attend following a fall (SAS Falls and Frailty Pathways Action Group). •Promote ‘Ask, Assess, Act’ approach, improve access to falls risk assessment and self management support.
Workforce & Practice Transformation •Develop a workforce competency framework for falls prevention and management. •Promote an outcomes based approach to falls prevention.
Partnership working •Work with Building Safer Communities, the third sector and Scottish Fire and Rescue to deliver primary prevention approaches. •Support and facilitate the Community Falls Leads Network.
Research and Innovation •Develop partnerships between delivery services, academia, industry, the DHI and SCTT. •On-going involvement in the European Innovation Partnership for Active and Health Ageing. •Raise awareness of new and emerging technologies to support falls prevention and management.
Knowledge Managem
ent •Capture and report learning and outputs from AILIP and other National Programmes •Report impact through AILIP and Falls Programme Measurement Frameworks •Communicate AILIP/Falls Programme through Managed Knowledge Network
Stakeholders
Older people and others at risk of falling Carers and families Older People’s services workforce H&SCPs Housing GPs NHS Boards Falls Leads Network SAS SFRS Care Inspectorate SSSC Scottish Care NES; HIS Third sector organisations incl Alliance National Policy makers Universities / Colleges (HEIs) AHP Federation International Partners Community Planners Improvement Bodies
The transformational learning around access will be spread to all AHP Services
AHPs will work in partnership with the people of Scotland to enable them to live healthy, active, and independent lives, by supporting personal outcomes for Health and Well Being. The ethos of Active and Independent Living will underpin all community development.
Assumptions
Monitoring and evaluation
Please refer to Individual Work streams for additional assumptions
Please refer to Individual Work streams for additional Measures
External Factors Please refer to Individual Work streams for additional external factors
Resources agreed and developed to support self management, early intervention for H&WB
The benefits of technology to drive self management, early intervention and H&WB will be spread Spread of multi-agency partnership working will be accelerated to support self management, early intervention for H&WB.
Population will have direct access to an AHP where appropriate
Population will have access to once for Scotland evidence based resources to support self management, early intervention for H&WB
Population will benefit from technologies to support self management, early intervention for H&WB
Population will benefit from multi-agency pathways to support their self management, early intervention for H&WB.
December 2017 December 2019 2020 and beyond
Appropriately skilled and developed workforce is contributing to the health and care needs of Scotland in a cost efficient and person centred way.
Health & Well Being •Review/update NHS Inform’s Falls Information Zone. •Support ongoing development of Falls Assistant appl •Produce/share widely short film on falls prevention. •Explore use of ‘brief interventions’ for falls prevention (in partnership with Public Health Wales). •Work with stakeholders on primary prevention focus in the Falls and Fracture Consensus Statement.
2016-2018
Testing of workforce tool and development of staff to undertake transformational change
Workforce tool influencing requirements and staff leading transformational change
Introduction of Health & Well-Being Outcomes Increased Focus on Personal Outcomes Lack of Awareness of the AHP contribution to H&SC Long waits to access many CYP & Adult AHP Services High number of population with disabilities not in employment Aging Population living with complex needs utilising more resources Underutilisation of technology to drive innovative practice Increased Demand on Health & Social Care Services Integration of Health & Social Care Increasing Challenges on GP and Primary Care Services Health & Social Care Workforce Challenges
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Appendix A1 – Falls Health & Wellbeing activities
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• Review/update NHS inform’s Falls Information Zone. • Review/update of Up and About Booklet. • Support ongoing development of Falls Assistant appl • Produce/share widely short film on falls prevention. • Explore use of ‘brief interventions’ for falls prevention (in partnership
with Public Health Wales). • Work with stakeholders on primary prevention focus in the Falls and
Fracture Consensus Statement. • Work with RoSPA on workplace as a conduit for falls prevention
education.
Appendix A2 – Falls Access activities
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Work with all H&SCPs, SAS , LWiC, the TEC programme and the Alliance to improve access to falls prevention and management services in the community setting, for older people the SAS attend following a fall (SAS Falls and Frailty Pathways Action Group).
Promote ‘Ask, Assess, Act’ approach, improve access to falls risk assessment and self management support.
Appendix A3 – Falls Awareness activities
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Take the Balance Challenge campaign, from July 2017. Falls awareness week 2017 – targeting people working with older
people. Falls, Fractures, Frailty and Osteoporosis Conference, May 2017. Publication of Falls and Fracture Consensus Statement, 2017 tbc.
Appendix A4 – Falls Partnership Working activities
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Work with Building Safer Communities, the third sector and Scottish Fire and Rescue to deliver primary prevention approaches.
Support and facilitate the Community Falls Leads Network. Work with Scottish Prison Service and Alzheimer Scotland on falls
prevention resource. Work with Technology Enabled Care Programme to improve falls
responder services. Partnership working is central to all activities in the Falls Programme.
Appendix A5 – Falls Research & Innovation activities
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Develop partnerships between delivery services, academia, industry, the DHI and SCTT.
On-going involvement in the European Innovation Partnership for Active and Health Ageing.
Raise awareness of new and emerging technologies to support falls prevention and management.
Appendix A6 – Falls Workforce & Practice Transformation
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Develop learning and development guidance for falls prevention and management (with NES).
Customise the NZ Healthcare Quality Commissions 10 Topics learning resource.
Work with UK College of Paramedics to develop falls elearning package.
Promote an outcomes based approach to falls prevention.