RESHAPING CARE FOR OLDER PEOPLE

Val Hatch NHS Fife, Martin Thom Social Work and Kenny Murphy Fife Voluntary Action

Intermediate Care

Hospital at Home

Patient/Service User

INTRODUCTIONINTERMEDIATE CARE & SUPPORT SERVICES

COMPONENT PARTS• Hospital at Home• Intermediate Care• Home Care

Intermediate Care Framework in Fife also includes• Independent Sector Beds• Alan McLure / Valley House

Single Point of Access for hospital discharge being developed thought the discharge hub at Victoria Hospital

Community Life

Assessment & Clinical Care

Patient

HOSPITAL @ HOME

Activity

Net Budget £2.205M

A community clinical assessment and care model that support people at home as an alternative to hospital admission

Provision

Implementation Plan

DWF April 2012

KLM July 2013

GNEF Sept/Oct 2013

Total New Patients

Ave LoS 5-8 days

Age Criteria Adults

Suitable Conditions• Infection, eg. Chest, urine, cellulites• Delirium• Falls – no lower limb fracture• Exacerbation of Chronic Disease• Reduced mobility related to illness/accident• Dehydration

Feedback from users

Positive and nearly always about being cared for at home.

Investment from Change Fund £2.205M

Community

Care At Home

Patient/Service User

INTERMEDIATE CARE TEAMS

Activity

A multi-disciplinary team of practitioners who prodie a period of rehabilitation ina persons home.

Focussed on both prevention of admission and early supported discharge from hospital.

Co-located in three areas in Fife:• QMH• Whyteman’s Brae• Adamson

Provision

Approximately 600-670 new referrals each month

Ave Los 21 days

Age Criteria over 65’s

Feedback from users

No structured process to measure, however evaluation indicated a high level of satisfaction

New funding provided through LUCAC £500,000

System

Community

Service User

DISCHARGE HUB

What we have done

2 Social Work Service Reablement Occupational Therapists, 6 NHS Fife Patient Flow Co-Cordinators and 1 Administrative Support

Purpose

To maintain patient flow from hospital focussing on support for discharge for frail complex patients focussing on return home.

To provide quicker access to;• Community rehabilitation services• Homecare services• Downstream and/or intermediate care bed

options• Reduce delays

Provision• Support across all hospitals in Fife• Fully implemented in VHK by end December

2013

Activity

In 4/5 wards approx 40 individuals per week a large number of which are going directly home.

Investment

LUCAC / NHS Fife £321,550

Social Work Service £84, 000

*(Area Team Link Social Workers Up to £237, 500)

System

Community

Service User

HOME CARE

ActivityNet Budget £18MCurrent overspend of £3.156M

Service UserDeveloping a model to support people to live at home, as independently as possible through adopting and delivering a reablement approach across all Care at Home provision.

•3000+ individual packages•1.2M hours of care at home•Telecare clients 12/13 = 1,287•Community alarms 12/13 = 6,974

Community Benefits

Supports safe maintenance of individuals

at home and within the community for as

long as possible and promotes

independence and community

integration.

System

Increased number of Home Carers,

Home Care Managers, Specialist

Reablement Occupational therapists and

Home Care Reablement Training Staff all

employed through Change Fund

Investment of £2M.

Telecare investment of £350,000.

Customer Satisfaction• Home care (November

2012) 91% satisfied• Telecare (February 2013)

93% satisfied• Community Alarms

(February 2013) 96% satisfied

System

Community

Service User

INTERMEDIATE CARE BEDS

What have we done

2 local Authority Homes (14 beds)

3 Independent Sector Homes (20 beds)

Service User Benefits

Access to a safe and enabling environment where the focus is on improving well-being, confidence, resilience and skills improvement. That aims to return individuals to live safely within their own homes.

Community Benefits• Reduces unnecessary long term care

placements and admission to hospital.• Assists to facilitate discharge from hospital.• Supports a safer re-integration home and into

the community

System Benefits• Opportunity to provide intensive reablement

within a supportive environment to build skills and resilience and allow individuals to return to live within their own homes.

• Allows detailed holistic assessment of skills etc. to ensure that no-one is admitted into long term care unless that is the most appropriate resource to meet their needs.

Investment

Change Fund £400,000 for independent sector

home provision.

Fife Council investment in local authority care home

provision £254,436 for both Valley House and Alan

McLure.*

System

Community

Service User

Investment: £70.542m Older Peoples Social Work services provide support people to live as independently as possible within their own communities. The service has over 1590 staff members, and in addition to assessment, care management and the protection of older people at risk of harm across Fife, we provide a wide range of in-house and external services, mostly aimed at protecting individuals who are most at risk in the community. The services provided include Long Term Care placements and funding, Day and Respite care facilities, care at home services, and a number of services to prevent admission into long term care, and hospitals. The change fund is being used to change a number of these models and services, and by working in partnership we hope to continue to develop sound models that will shift the balance of care and reshape services for older people across Fife.

RESHAPING CARE

System

Community

Service User

LIFE LONG LIVING

11 Projects

Not just “capacity building” but making real contributions to

Preventative & Anticipatory Care Proactive Care & Support at Home Effective Care at Time of Transition Hospital & Care Homes

Change Fund Investment £500,00