Date: 17 th January 2014 Author: Sylvia Morrsion, Head of Primary Care and Community Services

Transcription

1 (Paper No 13/171) Renfrewshire Community Health Partnership Committee Date: 17 th January 201 Author: Sylvia Morrsion, Head of Primary Care and Community Services Agenda Item: Change Fund Mid-ear Review Report 1 Purpose 1.1 The purpose of this report is to provide the Renfrewshire Community Health Partnership Committee with a copy of the Mid-ear Review Report submitted to the Scottish Government on behalf of the local partnership. 2 Background 2.1 This report should be read in conjunction with the papers relating to the Reshaping Care of Older Peoples Services previously presented and discussed at Committee. Recommendations The Committee is asked to note the content of the report as at October

2 RENFREWSHIRE PARTNERSHIP CHANGE FUND 2013/201 MID-EAR REVIEW REPORT OCTOBER

3 Contact Details To ensure our records are up-to-date, please complete for all four partners: Joint Strategic and Operational Leads Name Job Title Address Shiona Strachan Head of Adult Services, Social Work Telephone # Name Job Title Address Sylvia Morrison Head of Primary Care and Community Services, Renfrewshire CHP sylvia.morrison@ggc.scot.nhs.uk Telephone # NHS(Acute) lead Name Job Title Address John Kennedy Head of Acute Services john.kennedy@ggc.scot.nhs.uk Telephone # Third Sector Lead Name Alan McNiven Job Title Chief Executive, Engage Renfrewshire Address AMcNiven@EngageRenfrewshire.com Telephone # Independent Sector Lead(s) Name Robert Telfer Job Title Development Officer Address robert.telfer@scottishcare.org Telephone # Other Key Contacts (if any e.g. overall Project Managers/Officers, Development Managers/Officers etc.) Name Teresa Lavery Job Title Change Fund Project Manager Address teresa.lavery@renfrewshire.gov.uk Telephone #

4 Carers Support Lead Name Diane Goodman Job Title Manager, Renfrewshire Carers Centre Address Telephone #

5 Change Fund 2013/1 Mid-ear Review Partnership Renfrewshire Contact Name(s) Teresa Lavery Change Fund Project Manager & Job Title(s) Address Telephone # Date of 25 October 2013 Completion 1. Examples of impact Please complete a case study template (Annex 1) describing at least one achievement that your partnership has made through use of the Change Fund for each of the Reshaping Care Pathway workstreams (i.e. we would like at least 5 in total to be submitted): Preventative and Anticipatory Care; Proactive Care and Support at Home; Effective Care at Times of Transition; Hospital and Care Home(s); Enablers. Each case study should be no more than one page long, with at least one of the case studies highlighting either a direct or an indirect impact on carers. Question 7 below contains short descriptors of interventions in the pathway. 2. Learning from what hasn t worked as well as anticipated The Change Fund has been an opportunity for Partnerships to explore innovations that are Proof of Concept or Tests of Change. Please describe any shareable learning gained from initiatives where a decision not to continue has been taken e.g. where barriers to progress were encountered or the initiative was not found to be effective. The Partnership funded an out of hours extension to the RES return home service for older people in A&E. The initiative is currently being evaluated, but early indications are that the service was not meeting the higher level of out of hours demand anticipated and the hours of service were calibrated accordingly. The lessons learned are the importance of constant review of services, performance and targets and the need for capacity to make changes in a reasonable timescale. The Partnership is currently evaluating the Change initiatives introduced in ears 1 and 2 of the Change Fund programme. An evaluation report will be submitted to the next meeting of the Change Fund Implementation Sub Group in late November

6 3. Option Appraisal Please describe any option appraisal approaches used to decide Change Fund investment priorities e.g. whether applied to all / only selected initiatives and who was involved. The Renfrewshire Partnership has applied needs analysis, using an evidence base which includes the findings of consultations with service users and carers and other stakeholder groups. Proposals have been assessed against the key outcomes: reducing levels of delayed discharge, avoiding unnecessary admission to hospital and capacity building. A pro forma has been used and a Project Initiation Document required for every proposal, to support the Change Fund Implementation Sub Group in its appraisal of options. The process was adapted to support third sector and community engagement in the process. JIT contribution to the options appraisal process has been as a friendly challenger and has been a regular input to the partnership activity. The Partnership has agreed (15 October 2013) a set of options appraisal criteria and methodology to be applied to Change Fund initiatives among other proposed changes and service developments being considered as part of the 10 ear Joint Commissioning Plan process to be completed by December Use of Data and Information Please describe your local progress and any barriers to effective use of data and information between partners (both within and out with the statutory sector). There is in place an information sharing protocol in place between Renfrewshire Council and NHSGGC. Work is ongoing to develop effective data sharing arrangements locally. Sharing of basic service data has now become routine and effective trend information is now available to managers as well as a scorecard of performance indicators tracking progress in key areas. Access to the Edison database on delayed discharges has allowed the production of up to date management information to supplement the monthly information published by the ISD. The Joint Services are using the SWIFT client information data base but there are IT systems challenges for staff. We are developing portals locally, the plan being to pilot these initially in Children s services. IRF and SPARRA data have been made available to the partnership. 6

7 5. Improvement support Please provide details of any support you would welcome. The Partnership values the ongoing input from JIT as friendly challenger locally and its support to local partnership development work. The Partnership also values the national learning and benchmarking events which produce examples of good practice at a national level. The Partnership is also pleased to be using the input of the Institute of Public Care in the development of the 10 year joint commissioning plan. 7

8 6. Budget 2013/1 Please insert details of your 2013/1 Change Fund budget and the proportion of spend aligned to each of these 5 workstreams: 2011/ / /1 SG Allocation 2.110m 2.10m 2.10m Additional Local Resources (if 0.650m 0.650m any) Carry Forward 0.872m 0.912m Total Allocation 2.110m 3.932m 3.972m ear-end Spend 3.026m 3.53m (anticipated) Anticipated Carry Forward to 201/ m Direct spend on carers (yearend spend) Indirect spend on carers (yearend spend) N/A 2, ,000 (anticipated) N/A 1% 1,36,932 (anticipated) 2011/12 (year-end spend) 2012/13 (year-end spend) 2013/1 (anticipated year end spend) Preventative and Anticipatory Care Proactive Care and Support at Home Effective Care at Times of Transition Hospital and Care Home(s) Enablers Total (should equal 100%) % 100% % % % 100% 15% 30% 27% 2% % 100% 23% 3% 27% 13% % 100% 7. Assessment of Spread The Reshaping Care Pathway represents bundles of interventions, approaches or actions and the related enablers which collectively improve outcomes for older people. As you take forward Joint Commissioning, it is important to understand the extent to which you have spread new approaches and improvements so that you can understand where and when future gains can be anticipated. Therefore we invite Partnerships to complete a self-assessment of spread as at September 2013 by assigning a position statement 0-5 to each approach or intervention in the pathway. 1 Carry forward has been earmarked provisionally for areas of growth or pressure in community services RES, care at home and care homes 8

9 Spread Self-Assessment Position Statement Value 0 No agreed plan to implement the approach / intervention / improvement action Agreed plan to take forward the approach / intervention / improvement action but 1 not yet began to implement Testing / implementing the approach / intervention / improvement action in a 2 minority of localities / sites / teams / older people / carers The approach / intervention / improvement action has spread to most localities / 3 sites / teams / older people / carers The approach / intervention / improvement action has spread to all localities / sites / teams / older people / carers but is not yet fully embedded in routine practice The approach / intervention / improvement action is fully embedded in all localities 5 / sites / teams / older people / carers and there is an agreed plan to sustain this Build social networks and opportunities for participation Early diagnosis of dementia Prevention of Falls and Fractures Information & Self- Management & Self-Directed Support Prediction of risk of recurrent admissions Anticipatory Care Planning carers Preventative and Anticipatory Care We are mobilising community support through volunteering, building community capacity, collaborations and social enterprises that promote participation and meaningful activity for older people living at home and in care homes. We continue to work to increase the number of people with dementia who have a diagnosis as this improves access to support and services for the family. The Partnership is implementing the recommendations of Up and About: a whole system pathway for the prevention and management of falls and fragility fractures. Practitioners and services signpost older people towards community and third sector resources that help them to stay well, to manage their conditions and provide useful and accessible information and advice on the choices they have about their future care, support and housing. This includes post diagnostic support for people affected by dementia and information and support required to adopt personal budgets. Community health and social care teams routinely use a risk prediction tool (e.g. SPARRA) and local health and social care data and intelligence to identify older people who are frail and at greatest risk of emergency admission to hospital or care home. Care providers support frail older people and their carers to develop Anticipatory Care Plans (ACPs): a summary or shared record of the preferred actions, interventions and responses in the event of an anticipated deterioration in the health of the person or their carer. Our health and care staff routinely identify carers and are able to signpost them to information, advice and support from social work, carers centres and other agencies to help them to stay well and be supported to continue in their role. Value (0-5)

10 Suitable and varied housing and housing support Responsive flexible, selfdirected home care Integrated /Care Management Carer Support and Respite Rapid access to equipment Timely adaptations, including housing adaptations Telehealthcare Reablement & Rehabilitation Specialist clinical advice for community teams NHS2, SAS and Out of Hours access ACPs Preventative and Anticipatory Care We are investing in handyperson services, housing support, making better use of our existing stock of sheltered housing and developing new specialist provision to help older people maintain their independence and reduce the risk of accidents at home. Proactive Care and Support at Home All providers of care and support at home adopt a doing with approach and formulate packages of care and support around the individual s personal goals. This includes the opportunity to adopt personal budgets for care and support. Multi-disciplinary community health and social care teams adopt an integrated case / care management approach to monitor and proactively support frail older people with complex and changing needs at greatest risk of emergency admission to hospital or care home. We provide opportunities for short breaks to help carers continue to provide care, helping reduce isolation, providing a better quality of life and maintaining carers health and wellbeing. There is effective and timely access to health and social care equipment and adaptations and this is an integral part of mainstream community care assessment and service provision. We have streamlined access to adaptations and alterations which help older people to maintain their independence at home. The partnership provides remote monitoring and assistive technology for older people with complex care and support needs who require this technology to remain supported in their own home. Effective Care at Times of Transition Health and care practitioners adopt an enabling approach and all providers have a focus on maintaining independence, recovery, rehabilitation and re-ablement. Primary and community health and care staff, including voluntary and independent sector partners, are supported by access to a range of specialist practitioners for advice on common important conditions in older people such as dementia, continence, nutrition and tissue viability. Community teams share essential information from ACPs (e.g. electronic Key Information Summary) with local emergency and out of hours services and with SAS and NHS2. Value (0-5) Value (0-5) 5 5 Value (0-5) 5 10

11 Range of Intermediate Care alternatives to emergency admission Responsive and flexible palliative care carers Medicines Management Access to range of housing options Urgent triage to identify frail older people Early assessment and rehab in appropriate specialist unit Prevention and treatment of delirium Effective and timely discharge home or to intermediate care Medicine reconciliation and reviews Carers as equal partners Specialist clinical support for care homes Effective Care at Times of Transition Working alongside NHS2, SAS and Out of Hours services we provide rapid access to a range of enabling assessment and treatment services at home, in minor injuries units, day hospitals, community hospitals and care homes as safe and effective alternatives to acute hospital admissions and to support timely discharge. We provide timely access to community based support for palliative and end of life care to increase the proportion of older people who are able to die at home or in their preferred place of care. We promote shared decision making and make sure that carers are informed and supported to help them continue in their role when the health of the person they care for deteriorates or they move to another care setting. Joint working between GPs, community pharmacists, mental health teams and geriatricians reduces polypharmacy for older people through mindful prescribing, review and reconciliation of medicines and use of pharmaceutical care plans. We support older people and their carers to administer and take medication safely. The range of intermediate care services provided includes timely accessible housing options for people whose functional ability has acutely declined. Hospital and Care Home(s) Pathways through A&E and admissions wards are configured to identify frail older people with physical, functional and cognitive impairments who will benefit from coordinated comprehensive geriatric assessment. Frail older people with physical, functional and cognitive impairments and those who have fallen are pulled to access multi-professional Comprehensive Geriatric Assessment within 2 hours of emergency admission to hospital. Pathways through acute hospitals minimise boarding for frail older people and care staff are trained to prevent, detect and effectively manage delirium. All partners work together and with Scottish Ambulance Service to optimise use of estimated date of discharge, improve discharge planning and eradicate delayed discharges, including delays in short stay specialty beds and for Adults with Incapacity. Medicine reconciliation is routinely undertaken for older people on admission and at discharge from hospital and care homes, and antipsychotic prescribing is minimised. We identify the carer at an early stage when the person is admitted to hospital and ensure that the carer is involved in the care, rehabilitation and discharge planning. We provide specialist clinical support to enable care homes to have a greater role in intermediate care and to support staff to care for older people with dementia and palliative / end of life care needs. 11 Value (0-5) 5 3 Value (0-5)

12 Outcomes-focussed assessment Co-production Technology/eHealth/Data Sharing Workforce Development/Skill Mix/Integrated Working Organisational Development and Improvement Support Information and Evaluation Commissioning and Integrated Resource Framework Enablers Our providers of care and support deliver personalised care through assessments which focus on personal outcomes and goals agreed with the older person (and their unpaid carer). Services are planned and delivered in an equal and reciprocal relationship between professionals, people using services, their families and the community. We routinely share information across professionals and teams in line with agreed data sharing protocols and using the capability of emerging technology. We are developing a multi-professional workforce that is integrated, capable and fit for the future with core generic skills and appropriate specialist competencies. We engage and communicate effectively with all partners, with our workforce and the public, and collaborate across professions and sectors to strengthen strategic leadership for change and to build improvement capacity and capability. We routinely use measurement for improvement and feedback performance measures to our staff and to the public to lever and assure quality. Statutory, community, third and independent sectors, users, carers, providers and commissioners of care come together to agree long term service development and investment proposals including where and how resources should shift from current services and care models to new arrangements. We are using the Integrated Resource Framework to lever a shift in the totality of the partnership spend on service and support for older people. Value (0-5) Any additional comments? Preventative and Anticipatory Care In relation to falls prevention, it should be noted that there is a great deal of activity in service delivery and development and general agreement on forward planning issues to integrate the activity. The Falls Subgroup, which is representative of all Health & SW partner agencies including, SAS and Care Home Sector, is benchmarking the local position against 12

13 'Up & About' good practice document. We are also working with other Smartcare Scottish partners to develop improved, evidence based & consistent care pathway. We are working with IM&T to enable information sharing across partner agencies. This work is at an early stage, with future planning and development work being identified, but is progressing steadily. There has been a rise in the use of Direct Payments amongst older service users and their carers and there is a multi-service users steering group currently planning the roll out of DP with a pilot underway under the aegis of SDS. The Partnership is also supporting the delivery of the platinum telecare services which support people to live at home. The further development of telecare services has been supported by the Change Fund. The Change Fund is also providing match funding for the European Smartcare Initiative, which focuses on dementia and telecare. The Partnership also supports the implementation of the NHSGGC framework on supported self care, with a range of activity around patient information and patient education and peer support. self management is provided via RES and care at home services and the telecare service. Local activity on self management includes the work of the health improvement team and community development approaches such as AgeFest (annual event promoting healthy lifestyles by and to older people in Renfrewshire). The Change Fund provides match funds for the European Initiative on the management of long term conditions, United Health. There is active development and roll out of the use of SPARRA amongst GPs in Renfrewshire, linking with RES to identify older people at risk of readmission to hospital and to support anticipatory care planning. Effective Care at Times of Transition In relation to specialist clinical advice for community teams, local spread and impact are good. The Change Fund has supported the targeting of resources to build strong links between primary care services and care homes, providing specialist staff (e.g. tv nurse, podiatrist, CPN support) and supporting GP engagement with care home residents, their families and care home staff in anticipatory care planning. In relation to access to a range of housing options, it should be noted that demand outstrips supply. Demand remains very high for specialist housing and for the range of adaptations for people to remain within their own homes. The Change Fund has been used to add capacity to the aids and adaptations programme locally, to provide housing advice for older people, a care and repair service, access to social activities and the Food Train shopping service. The Change Fund is currently funding two reviews of housing for older people extra care housing and sheltered housing, the studies being undertaken by 13

14 Craigforth Research Unit (reports expected to be available to the Partnership early next year) Hospitals and Care Homes In relation to carers as equal partners, we are working to further develop progress around carers pathways and support in the hospital settings. It should be noted that early feedback on the Change Fund initiative Carer Pathway Liaison, the post managed by the Renfrewshire Carers Centre, is very positive and improvements in this area are anticipated. Current work developing specialist support for care homes includes: -GNS support to Local Authority (LA) Care Homes in implementation of their Falls prevention & Management Strategy has demonstrated a reduction in falls & fractures in pre & post audit. - GNS Clinics in LA CHs has prevented avoidable hospital admissions through interface with Primary Care services & non medical prescribing - CPN attachment to CHs has supported CH staff in management of care for residents with complex & enduring mental illnesses. - Palliative care & EOL Care Pathway support provided by Macmillan GP Facilitator, Macmillan Nurse Specialist & local Hospices has improved the quality of care & residents choice through the use of ACPs(Anticipatory Care Plans) & SPAR ( Supportive Palliative Action Register ). - Introduction of the JIC (Just in ) boxes in November will be supported in CH by DNS. - RES multidisciplinary support to CHs has prevented avoidable hospital admission, eg through medicines review by Interface Pharmacist & facilitated early supported discharge, eg through the rehabilitation programme in CH. The Partnership supported the establishment of a care providers forum and continues to support its regular meetings in pursuit of practice development. The forum supports sharing of good practice, information and access to training. The most recent meeting addressed a range of topics including infection control, oral health and end of life care practice. The forum has a high attendance level and is supported by the partnership s representative from Scottish Care. In relation to medicines management, spread and impact are good but some services (e.g. pharmacy) may not be fully embedded yet. However, the majority of care homes are now engaging in one or more of the initiatives. This has been supported by the work of the Scottish Care officer whose post is funded by the Change Fund. Enablers In relation to technology, ehealth and data sharing, there is still room for improvement in relation to information management protocols and processes. In relation to commissioning and the integrated resource framework, there is currently a great deal of activity on partnership work on joint commissioning to 1

15 establish development agreements on investment proposals and shifting resources. The 10 ear Joint Commissioning Plan is expected to be completed in Dec 2013 following a public stakeholder engagement which will be the culmination of a programme of development and consultation over the summer and autumn The 10 ear Joint Commissioning Plan will provide a strategic framework for future commissioning of services. In relation to IRF issues, the Partnership is working with ISD colleagues at national and local level to contribute to the development of the Information and Intelligence Framework to Support Health and Social Care Integration at national level. Thank you for taking the time to complete this mid-year review. Please return this template, along with at least 5 case studies using the pro-forma in Annex 1, to Mohamed.omar@scotland.gsi.gov.uk by Friday 27 September

16 Annex 1 Examples of Impact Partnership Renfrewshire Name of Initiative Highlighted Rapid Response Team Extended Service Hours Date of Submission 25/10/13 Primary Contact Marian McGhee marian.mcghee@ggc.scot.nhs.uk Telephone Pathway: Effective Care at Times of Transition Summary The Partnership decided to extend the hours of the Rehabilitation & Enablement (RES) Rapid Response Team until 8pm to support older people being discharged from hospital and/or to prevent avoidable hospital admissions. The team works with hospital staff and care at home staff to support discharge from hospital to care at home or to care homes. The team supports triage at A&E to identify people who can receive community-based services as alternatives to hospital admission and liaises with other community services to put in place treatment, care & support packages, including community equipment, for patients in their own home. What was the issue you were addressing or working on? Avoiding unnecessary hospital admissions & delays in patients discharge. What did you do? (Intervention(s), organisations involved, when it happened, development or tools used including use of Change Fund, JIT involvement) A team of Nurses & AHPs has been established to provide rapid responses to GPs and hospital staff for patients whose admission to hospital can be prevented or whose discharge from hospital can be accelerated through provision of treatment & support from community health services. The team provides an out of hours service until 8pm to increase accessibility & potential for early supported discharge from A&E and prevention of avoidable hospital admission into the early evening. The team respond to referrals from A&E within 1 hour & to referrals from GPs within hours. What were the outcomes/benefits or otherwise? (What happened and what was gained or lost from this? When were the benefits realised? Would you do anything differently? What is/was your timeline?) This initiative has enabled community health services to offer community-based options, into the early evening, to older people which prevent unnecessary hospital admission and has contributed to the very significant reduction in bed days lost due to delayed discharge, supporting patients to return home with an appropriate health and care package which is tailored to meet their needs & those of their carers. The initiative is funded until the end of March 201 & is currently being evaluated to inform long term plans. Additional contacts (to find out more) (People, organisations, link(s) to further information, if available) Pauline Robbie RES Team Lead Paisley Craig Ross RES Team Lead West Renfrew

17 Annex 1 Examples of Impact Once submitted, this case study will be published to the JIT website. To help users find case studies relevant to their area of interest, this case study should be tagged with the following search terms (e.g. Reshaping care, re-ablement, community capacity, third sector, preventing admissions, intermediate care) In order to help us best sort the case studies please enter a into each and every box you think this applies to, being cognisant of the primary pathway chosen on the previous page: Preventative and Anticipatory Care Build social networks and opportunities for participation Early diagnosis of dementia Prevention of Falls and Fractures Information & Self- Management & Self-Directed Support Prediction of risk of recurrent admissions Anticipatory Care Planning carers Suitable and varied housing and housing support y Proactive Care and Support at Home Responsive flexible, selfdirected home care Integrated /Care Management Carer Support and Respite Rapid access to equipment Timely adaptations, including housing adaptations Telehealthcare y Effective Care at Times of Transition Reablement & Rehabilitation Specialist clinical advice for community teams NHS2, SAS and Out of Hours access ACPs Range of Intermediate Care alternatives to emergency admission Responsive and flexible palliative care carers Medicines Management Access to range of housing options y y y Hospital and Care Home(s) Urgent triage to identify frail older people Early assessment and rehab in appropriate specialist unit Prevention and treatment of delirium Effective and timely discharge home or to intermediate care Medicine reconciliation and reviews Carers as equal partners Specialist clinical support for care homes y y Enablers Outcomes-focussed assessment Co-production Technology/eHealth/Data Sharing Workforce Development/Skill Mix/Integrated Working OD and Improvement Support Information and Evaluation Commissioning and Integrated Resource Framework y y Partnership Renfrewshire 17

18 Annex 1 Examples of Impact Name of Initiative Highlighted Carer Pathway Liaison Date of Submission 25/10/13 Primary Contact Diane Goodman diane@renfrewshirecarers.org.uk Telephone # Pathway: Preventative and Anticipatory Care Summary The Carer Pathway Liaison Worker s post is there to develop and maintain a clear carer pathway within health and social care. This includes a pathway for staff to refer carers to the centre. The aim is to educate staff so they can identify more carers of older people and refer them to the centre for support, thus enabling them to continue in their caring role. The post involves developing partnership working with health and social care staff and delivering training to these teams to increase their carer awareness. What was the issue you were addressing or working on? Avoiding unnecessary admissions to hospital and reducing delayed discharge through supporting carers in their caring role. What did you do? (Intervention(s), organisations involved, when it happened, development or tools used including use of Change Fund, JIT involvement) -educating health and social care staff on the importance of their role in the identification of carers and referral processes; jointly identifying and addressing training needs for carers with RES & DN staff and care at home staff; 2 half days spent weekly within the 2 RES teams- informing staff of the centre services and encouraging them to identify carers; shadowing RES staff on home visits was undertaken in the early months; going on joint home visits with staff where requested; encouraging staff to distribute and ideally support carers to complete carer self- assessments and the full Carers Assessment; jointly facilitating the Carers Champion group; initial links with the discharge team at the RAH; establishing links with social work locality teams, learning disability, and sensory impairment teams- had initial contact with team leaders What were the outcomes/benefits or otherwise? (What happened and what was gained or lost from this? When were the benefits realised? Would you do anything differently? What is/was your timeline?) Health and social care staff are becoming more carer aware; strengthening partnership working between the centre and health and social care teams; new Carers of older people are being identified by staff and referred on for support; 52 new referrals to the carers centre from work with health and social care staff; new training courses being designed for carers; new support groups established for carers; as the post is developing, staff are requesting joint visits to families with the Carers Worker Additional contacts (to find out more) (People, organisations, link(s) to further information, if available) Diane Goodman, Manager Renfrewshire Carers Centre diane@renfrewshirecarers.org.uk Marian McGhee, chair, Joint Planning Performance and Implementation Group for Carers marian.mcghee@ggc.scot.nhs.uk 18

19 Annex 1 Examples of Impact Once submitted, this case study will be published to the JIT website. To help users find case studies relevant to their area of interest, this case study should be tagged with the following search terms (e.g. Reshaping care, re-ablement, community capacity, third sector, preventing admissions, intermediate care) In order to help us best sort the case studies please enter a into each and every box you think this applies to, being cognisant of the primary pathway chosen on the previous page: Preventative and Anticipatory Care Build social networks and opportunities for participation Early diagnosis of dementia Prevention of Falls and Fractures Information & Self- Management & Self- Directed Support Prediction of risk of recurrent admissions Anticipatory Care Planning carers Suitable and varied housing and housing support Proactive Care and Support at Home Responsive flexible, selfdirected home care Integrated /Care Management Carer Support and Respite Rapid access to equipment Timely adaptations, including housing adaptations Telehealthcare Effective Care at Times of Transition Reablement & Rehabilitation Specialist clinical advice for community teams NHS2, SAS and Out of Hours access ACPs Range of Intermediate Care alternatives to emergency admission Responsive and flexible palliative care carers Medicines Management Access to range of housing options Hospital and Care Home(s) Urgent triage to identify frail older people Early assessment and rehab in appropriate specialist unit Prevention and treatment of delirium Effective and timely discharge home or to intermediate care Medicine reconciliation and reviews Carers as equal partners Specialist clinical support for care homes Enablers Outcomes-focussed assessment Co-production Technology/eHealth/Data Sharing Workforce Development/Skill Mix/Integrated Working OD and Improvement Support Information and Evaluation 19

20 Annex 1 Examples of Impact Commissioning and Integrated Resource Framework Partnership Renfrewshire Name of Initiative Highlighted Community Geriatrician Date of Submission 25/10/13 Primary Contact John Kennedy John.kennedy@ggc.scot.nhs.uk Telephone # Pathway: Hospital and Care Home(s) Summary The Change Fund supports a community geriatrician post at the RAH, providing early assessment at day hospital and rapid access clinics as means of comprehensive geriatric assessment and admission avoidance. The post holder also provides specialist advice to GPs, to the Rehabilitation and Enablement and DN Services and Care Homes. The rapid access specialist clinics take referrals from GPs and advise the community health services of alternatives to hospital admission when appropriate. The post holder participates in quarterly meetings where hospital and community health and care staff meet to consider operational improvement areas in services and pathways for patients. What was the issue you were addressing or working on? Avoiding unnecessary admissions to hospital by supporting community-based alternatives to hospital admission. What did you do? (Intervention(s), organisations involved, when it happened, development or tools used including use of Change Fund, JIT involvement) The Partnership agreed to allocate Change Fund monies to support this post, based in the hospital but working across hospital-based and community health services, building links between specialist hospital services and GPs and Care Homes in particular, providing early assessment day clinics and specialist advice to community health staff. What were the outcomes/benefits or otherwise? (What happened and what was gained or lost from this? When were the benefits realised? Would you do anything differently? What is/was your timeline?) Older people have rapid access to hospital-based assessment services without having to be admitted to hospital unnecessarily. Community health staff have speedy access to specialist advice in provision of treatment and services for older patients. The post is currently funded to the end of the Change Fund programme. Additional contacts (to find out more) (People, organisations, link(s) to further information, if available) Janice.murtagh@ggc.scot.nhs.uk Deborah.mack@ggc.scot.nhs.uk 20

21 Annex 1 Examples of Impact John.kennedy@ggc.scot.nhs.uk Once submitted, this case study will be published to the JIT website. To help users find case studies relevant to their area of interest, this case study should be tagged with the following search terms (e.g. Reshaping care, re-ablement, community capacity, third sector, preventing admissions, intermediate care) In order to help us best sort the case studies please enter a into each and every box you think this applies to, being cognisant of the primary pathway chosen on the previous page: Preventative and Anticipatory Care Build social networks and opportunities for participation Early diagnosis of dementia Prevention of Falls and Fractures Information & Self- Management & Self-Directed Support Prediction of risk of recurrent admissions Anticipatory Care Planning carers Suitable and varied housing and housing support Proactive Care and Support at Home Responsive flexible, selfdirected home care Integrated /Care Management Carer Support and Respite Rapid access to equipment Timely adaptations, including housing adaptations Telehealthcare Effective Care at Times of Transition Reablement & Rehabilitation Specialist clinical advice for community teams NHS2, SAS and Out of Hours access ACPs Range of Intermediate Care alternatives to emergency admission Responsive and flexible palliative care carers Medicines Management Access to range of housing options Hospital and Care Home(s) Urgent triage to identify frail older people Early assessment and rehab in appropriate specialist unit Prevention and treatment of delirium Effective and timely discharge home or to intermediate care Medicine reconciliation and reviews Carers as equal partners Specialist clinical support for care homes Enablers Outcomes-focussed assessment Co-production Technology/eHealth/Data Sharing Workforce Development/Skill Mix/Integrated Working OD and Improvement Support Information and Evaluation 21

22 Annex 1 Examples of Impact Commissioning and Integrated Resource Framework 22

23 Annex 1 Examples of Impact Partnership Renfrewshire Name of Initiative Highlighted Telecare Date of Submission 29/10/13 Primary Contact Lorna Muir Lorna.muir@renfrewshire.gov.uk Telephone # Pathway: Proactive Care and Support at Home 1. Summary The Partnership has allocated Change funds to provide a range of telecare packages for older people living at home, and an installation service provided by appointed technicians.. This has reduced delays in installing telecare equipment needed for older people with a care package and complements the reablement approach to care at home, offering people support at home while promoting independent living. 2. What was the issue you were addressing or working on? The initiative was supported by the Partnership which wished to reduce levels of delayed discharge from hospital by eliminating or minimising waiting times for telecare installation to support older people living at home with a care package. 3. What did you do? (Intervention(s), organisations involved, when it happened, development or tools used including use of Change Fund, JIT involvement) The Change Fund provided a budget for the appointment of telecare technician staff and a range of telecare equipment for installation (non recurring) as well as multi funcational assistive technology.. What were the outcomes/benefits or otherwise? (What happened and what was gained or lost from this? When were the benefits realised? Would you do anything differently? What is/was your timeline?) Benefits are currently ongoing, minimising waiting times for telecare equipment for people either being discharged from hospital or in supporting a care at home package that helps avoid unnecessary admission to hospital. The assistive technology supports the assessment and risk management strategies for people living at home in the community and also enhances quality of life through meaningful activity. The Change Fund funding for equipment was non recurring in ear 2; the funding for the Telecare technicians is currently scheduled to terminate at the end of the Change Fund programme 5. Additional contacts (to find out more) (People, organisations, link(s) to further information, if available) 23

24 Annex 1 Examples of Impact Once submitted, this case study will be published to the JIT website. To help users find case studies relevant to their area of interest, this case study should be tagged with the following search terms (e.g. Reshaping care, re-ablement, community capacity, third sector, preventing admissions, intermediate care) In order to help us best sort the case studies please enter a into each and every box you think this applies to, being cognisant of the primary pathway chosen on the previous page: Preventative and Anticipatory Care Build social networks and opportunities for participation Early diagnosis of dementia Prevention of Falls and Fractures Information & Self- Management & Self-Directed Support Prediction of risk of recurrent admissions Anticipatory Care Planning carers Suitable and varied housing and housing support Proactive Care and Support at Home Responsive flexible, selfdirected home care Integrated /Care Management Carer Support and Respite Rapid access to equipment Timely adaptations, including housing adaptations Telehealthcare y Effective Care at Times of Transition Reablement & Rehabilitation Specialist clinical advice for community teams NHS2, SAS and Out of Hours access ACPs Range of Intermediate Care alternatives to emergency admission Responsive and flexible palliative care carers Medicines Management Access to range of housing options Hospital and Care Home(s) Urgent triage to identify frail older people Early assessment and rehab in appropriate specialist unit Prevention and treatment of delirium Effective and timely discharge home or to intermediate care Medicine reconciliation and reviews Carers as equal partners Specialist clinical support for care homes Enablers Outcomes-focussed assessment Co-production Technology/eHealth/Data Sharing Workforce Development/Skill Mix/Integrated Working OD and Improvement Support Information and Evaluation Commissioning and Integrated Resource Framework 2

25 Annex 1 Examples of Impact Partnership Renfrewshire Name of Initiative Highlighted Workforce Development - Dementia and Palliative Care Date of Submission 25/10/13 Primary Contact Lorna Muir lorna.muir@renfrewshire.gov.uk Telephone # Pathway: Enablers Summary The Partnership has allocated Change Fund monies to develop and roll out training for home care and care home staff in dementia and palliative care. This allows the delivery of packages of care in people s homes or care homes which supports them to live as independently as possible in the community for as long as possible, avoiding unnecessary hospital admissions. It also supports the ACP approach to supporting older people and their carers plan for future care needs, offering care at home or home care options to meet needs associated with dementia and palliative care. What was the issue you were addressing or working on? Reducing levels of delayed discharge from hospital by providing specialist care at home or in care homes in the community; avoiding unnecessary admissions to hospital by supporting communitybased alternatives to hospital admission; expanding and promoting choices for older people in anticipatory care planning; ensuring staff have the right skills to be able to appropriately and effectively support people at home. What did you do? (Intervention(s), organisations involved, when it happened, development or tools used including use of Change Fund, JIT involvement) The Partnership agreed to allocate Change Fund monies to support the development of workforce training in care at home and care home staff in dementia and palliative care. What were the outcomes/benefits or otherwise? (What happened and what was gained or lost from this? When were the benefits realised? Would you do anything differently? What is/was your timeline?) Older people with dementia or palliative care needs have the option of remaining at home/in their care home or returning home or to their care home after hospital, with staff being trained to provide the specialist care needed. The training programme being offered to care at home staff is currently funded to the end of the Change Fund programme but will continue thereafter through facilitator training that is accredited to allow continuous development. Additional contacts (to find out more) (People, organisations, link(s) to further information, if available) The training for care at home staff is being supported through Stirling Dementia Services Development Centre self study courses. Further details are available from Stirling or from 25

26 Annex 1 Examples of Impact Renfrewshire Care at Home service Managers. Once submitted, this case study will be published to the JIT website. To help users find case studies relevant to their area of interest, this case study should be tagged with the following search terms (e.g. Reshaping care, re-ablement, community capacity, third sector, preventing admissions, intermediate care) In order to help us best sort the case studies please enter a into each and every box you think this applies to, being cognisant of the primary pathway chosen on the previous page: Preventative and Anticipatory Care Build social networks and opportunities for participation Early diagnosis of dementia Prevention of Falls and Fractures Information & Self- Management & Self-Directed Support Prediction of risk of recurrent admissions Anticipatory Care Planning carers Suitable and varied housing and housing support Proactive Care and Support at Home Responsive flexible, selfdirected home care Integrated /Care Management Carer Support and Respite Rapid access to equipment Timely adaptations, including housing adaptations Telehealthcare Effective Care at Times of Transition Reablement & Rehabilitation Specialist clinical advice for community teams NHS2, SAS and Out of Hours access ACPs Range of Intermediate Care alternatives to emergency admission Responsive and flexible palliative care carers Medicines Management Access to range of housing options Hospital and Care Home(s) Urgent triage to identify frail older people Early assessment and rehab in appropriate specialist unit Prevention and treatment of delirium Effective and timely discharge home or to intermediate care Medicine reconciliation and reviews Carers as equal partners Specialist clinical support for care homes Enablers Outcomes-focussed assessment Co-production Technology/eHealth/Data Sharing Workforce Development/Skill Mix/Integrated Working OD and Improvement Support Information and Evaluation Commissioning and Integrated Resource Framework 26