Midlothian Health and Social Care Partnership

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1 Midlothian Health and Social Care Partnership the right care the right support the right time This document is a draft, work in progress version. It includes current thinking on priorities / direction and may change.

2 Background The population in Midlothian is increasing and people are living longer, healthier lives. As society changes so do the health and care needs of our communities. The integration of health and social care is one of the Scottish Government s top priorities and is designed to meet these needs. From mid-summer, Midlothian Council and NHS Lothian will be working together as a Health and Social Care Partnership governed by the Midlothian Integration Joint Board (IJB). MIDLOTHIAN HEALTH AND SOCIAL CARE VISION: People will lead longer and healthier lives by getting the right advice, care, and support, in the right place, at the right time. The new partnership means working together, with joint responsibility and accountability, in helping achieve better outcomes for Midlothian s people.

3 holistic recovery workingtogether prevention Achieving better outcomes Getting the right services at the right time Providing excellent quality care, treatment and support Staying healthy and well anticipatory care resilience building people accessible independence health planning together staying safe There are nine National health and wellbeing outcomes that apply to integrated care (see Appendix) outcome focused co-ordinated well-being communities

4 Criminal Justice Occupational Therapy and Physiotherapy Services included in the plan Physical Disability and Long Term Conditions

5 Planned Hospital In-Patient Services Children s Services such as education, health visiting, and children and families social work* Services not included in the plan Other Council Services such as leisure and transport However, we need to work together with all other services and partners to help tackle some of the big issues that affect our health and wellbeing. Examples include poverty, transport and the environment. * These services may be included in the future

6 More services at Midlothian Hospital. Rehabilitation for older people Screening and tests We will provide homebased blood pressure monitoring, target screening checks for people most at risk, and provide more tests at GP surgeries. Better health screening and checks Consider treating minor injuries at the Hospital More outpatient clinics at Hospital Local health services Rehabilitation for older people at the Hospital Ensure ambulance and A&E staff have the key information We will transfer beds from Liberton Hospital to Midlothian Hospital. This will help to support GPs so they have more time. More health care assistants Pharmacists working in GP practices Advanced training for nurses Better links between health and social work Improve GP premises GP premises We are building a new health centre for Loanhead. We will extend the Medical Centre in Gorebridge and we plan to improve facilities in Penicuik, Danderhall and Newbattle medical centres.

7 Dying at home We will set up a Palliative Care Steering Group to oversee the quality of care we provide and training for staff. Power of Attorney Encourage people to plan ahead so that families are able to legally make decisions on behalf of their relative and help people be discharged. Reablement helps people to regain skills and confidence. Prevent unnecessary hospital stays for dementia Promote Power of Attorney Enable people to die at home if they wish Put more money into Reablement Service Increase skills of nurses Care for people at home and support people to leave hospital Assess need for overnight social care Test discharge to assess Strong link between GPs and consultants Single contact for hospital discharge hub to use Make hospital in-reach team stronger Discharge to Assess This means carrying out assessment of people s needs at home, rather than when they are still in hospital. Hospital In-Reach We will employ additional Care Assistant, fund Red Cross and pilot a District Nurse in the team.

8 Area Targeting House of Care The House of Care model is a way of working with people with long term conditions. It means helping people to make decisions and set their own goals. It means developing people s skills and confidence to manage their own condition in their day to day life. Test House of Care in Newbattle and Penicuik Reduce health inequalities for disabilities Take part in area targeting project This project involves lots of different organisations working with the community to improve people s lives. The communities we will work with are Gorebridge, Woodburn and Mayfield and Easthouses. Increase dentist registration for older people Reducing health inequalities Fund advice surgeries for carers Midlothian Training Services Provide employment support including for mental health problems, substance misuse problems and learning disabilities. Fund Midlothian Training Services Support people in our new homeless facility Work with Empowerment Development Worker Empowerment Development Worker This worker is based in Mayfield and will work with community members to find ways to improve health. This is part of the Area Targeting project.

9 We will work with Commercial Services to carry out work to make homes dementiafriendly. Dementiafriendly homes Power of Attorney Encourage people to plan ahead so that families are able to legally make decisions on behalf of their relative and help people be discharged. Prevent unnecessary hospital stays for dementia Promote Power of Attorney Raise awareness about dementia Plan care before leaving hospital Single dementia team coordinated care Support for dementia Reduce avoidable hospital admissions More funding for support post-diagnosis Use more new technology Anticipatory care planning Family group conferencing Anticipatory Care Plans This helps people plan for the future so they can manage better if their health changes. Family Group Conferencing This is working with families so that people and their families are more in control of care and decisions about care. We will carry on funding this. MERRIT and the Dementia Team will work together to do this.

10 Minority ethnic carers We will support voluntary organisations to access language and interpreter services, and to provide ongoing support to carers from minority ethnic groups. Short breaks for carers Wee breaks supports carers to have flexible breaks from caring. We may also need to invest in more respite care. Reach carers from minority ethnic groups Hospital Inreach Carer Support Worker Carry on with Wee Breaks Develop a new Carer Strategy Support for carers Continue welfare advice sessions for carers at the Carer Centre Strengthen carer s rights Implement Self Directed Support for carers Identify hidden carers and make sure they are supported Use new technology to support carers Carer Rights There is new legislation that strengthens carer rights including the right to a carer support plan. New technology An example of the new technology we could use is Just Checking. This allows carers to monitor the cared-for person whilst they are away from home.

11 Reablement Service and MERRIT Reduce isolation and ill-health We decided to carry on funding Ageing Well, Voluntary Day Services and Red Cross Coordinators. The Coordinators help people to take part in activities in their community. Support people to be active and connected Make plans with people in case their health gets worse Rehabilitation beds at Midlothian Hospital More support for people leaving hospital Reablement helps people to leave hospital and return home. The service will be increased. MERRIT also supports people to leave hospital or to stay at home. It will now open in the evenings and at weekends, as well as through the week. Preventing falls and accidents We will prevent falls by offering more physiotherapy, exercise programmes and technology. We will work with the fire brigade and housing providers to reduce accidents at home. Prevent falls and accidents at home Review Day Hospital and Day Services Support for Older People Carry on with Care Home Nurse Advisor More step down beds for people leaving hospital Hospital at Home people treated at home instead of hospital

12 Macmillan Cancer Support Transforming Care After Treatment programme This aims to make sure people diagnosed with cancer are supported. People are assessed to find out what support they need. We will increase access to physical and social activity, healthy eating advice, and employment / benefits advice. Occupational Therapy At the moment people can get different Occupational Therapy support from social care and from health. Sometimes people are assessed twice and see different people for different things. We want to change this so the service is more joined up. Look at providing rehabilitation for under 65s at Highbank Improve ways to access Occupational Therapy Take part in Transforming Care After Treatment for cancer Support for long term health conditions Work with voluntary sector to develop peer support Test House of Care in Newbattle and Penicuik More weight management courses for people at risk of developing diabetes Coordinators for long term conditions House of Care The House of Care model is a way of working with long term conditions. It means helping people to make decisions and set their own goals. It means developing people s skills and confidence to manage their own condition in their day to day life. Coordinators Coordinators employed by the Red Cross will start to work with people aged under 65 with long term conditions. They will support people to take part in activities and groups. They aim to help people to stay healthy and reduce isolation.

13 Rehabilitation for people aged under 65 Highbank Care Home provides short-term rehabilitation. For example for people who leave hospital and need to regain skills before they go home. At the moment this service is only offered to over 65s, but we are looking at extending it to people under 65. This will help people leave hospital sooner and will prevent some people from going to hospital. Occupational Therapy At the moment people can get different Occupational Therapy support from social care and from health. Sometimes people are assessed twice and see different people for different things. We want to change this so the service is more joined up. Improve ways to access Occupational Therapy Look at providing rehabilitation for under 65s at Highbank Take action to address health inequalities Anticipatory care planning Work with voluntary sector to develop peer support Support for physical disabilities Make better plans with people about their future care Test House of Care in Newbattle and Penicuik Carry on implementing self-directed support Work with voluntary sector to provide advice about welfare reform House of Care The House of Care model is a way of working with long term conditions. It means helping people to make decisions and set their own goals. It means developing people s skills and confidence to manage their own condition in their day to day life. Self-directed Support Self-directed support gives people choice and control over the support they receive from social care. Some people can manage their support on their own, while others need help from friends and family, or a special organisation.

14 Audiology Clinics At the moment audiology clinics take place at Lauriston Buildings in Edinburgh. We would like to provide audiology clinics in Midlothian and we are looking at how to do this. Find out if audiology clinics can be provided in Midlothian Promote the use of screening tools for sensory impairment See Here is a new national strategy to improve the lives of hearing and sight impairment. Develop a See Hear action plan Support for sensory impairment Distribute information and equipment at libraries Improve access to communication supports Using libraries more You can already get replacement hearing aide batteries at libraries. We are looking at how we can use libraries more, for example to get replacement tubes for hearing aides. Improve links with specialist organisations like Deaf Action Increase staff awareness about sight and hearing loss Access to communication supports New legislation will increase access to British Sign Language support.

15 Autism Spectrum Disorder action plan The plan will include: -Getting information and advice -Accessing further education -Getting a job -Being involved in the community Preventing drug and alcohol problems We will spend less on specialist treatment and more on prevention and early intervention. For example counselling, therapies, access to physical activity. More peer support for mental health and substance misuse Spend more on preventing drug and alcohol problems Local action plan for Autistic Spectrum Disorder Integrated Substance Misuse Service Mental health and substance misuse needs of offenders Supporting mental wellbeing New Royal Edinburgh Hospital opens 2016 make sure Midlothian needs are met Single joint mental health service in place since 2008 Better access to psychological therapies and community support The needs of offenders We will improve access to psychological therapies for offenders. We will invest in SPRING a project that supports women at risk of offending. Better links between mental health and substance misuse teams Awareness raising campaigns to tackle stigma Mental health and substance misuse We will develop clear guidelines for working together and staff will attend each other s team meetings. We will make sure people with substance misuse problems have quick access to mental health services. Psychological therapies There will be a new team to assess people for psychological therapies. They will also help people to access other support. The team will work in different places across Midlothian and will be quick to access.

16 Day services, respite and short breaks People s needs are changing. We need to review Cherry Road, the Access Team and (name of respite service) to make sure they can support people with different needs and people of all ages. Hidden sight and hearing problems We have two sensory impairment champions in our learning disability services. Change day services, respite and short breaks Make sure care packages are right for people Create a joint health and social care service Identify hidden sight and hearing problems Develop a new local learning disability strategy Supporting learning disabilities Carry on introducing selfdirected support Build a housing unit for people with complex needs Provide more local day activities for younger people New housing unit We are building a new housing unit for 12 very complex needs. This will be in Penicuik. Make better plans with people about what to do when they are ill Encourage older people to be physically active Better Plans This includes making sure people have legal plans in place so that others can act on their behalf.

17 Expand Telecare Examples include: 1. Technology that helps people record information about their own health. This can be shared with staff if people choose. It can show if health is changing and if people are at risk 2. Just Checking technology that picks up on movement in a house and can provide peace of mind to carers Make Handyman Service sustainable Use telecare and smart technology more Coordinate support to people living in new homeless unit Housing and supporting people at home Better housing design so that dementia can live safely at home Redesign sheltered housing schemes Housing design and dementia Examples of supporting better housing design: developing design guidance for builders training and resources for maintenance staff and families Handyman Service This service will be continued. We will develop the service so that service users will pay for materials and an affordable charge for labour. Build housing unit for 12 complex learning disabilities Develop extra care housing in private sector Sheltered Housing We will work with Housing Associations to redesign some sheltered housing schemes so that they can support people with higher needs.

18 Signposting Area targeting project This project involves lots of different organisations working with the community to improve people s lives. The communities we will work with are Gorebridge, Woodburn and Mayfield and Easthouses. Support the Area Targeting Project and Empowerment Worker Carry on working with service user and carer groups to plan services Employ a Communication Officer for Health and Social Care Shared information about services and community activities Communication and community engagement Improve signposting to support Public and Carer members on the Health and Social Care Joint Board Carry out the actions in our Strengthening Engagement Action Plan This means supporting people to access community activities and resources like peer support or physical activities. We are looking at how we can do this better in GP surgeries, as well as funding services like the Coordinators. There will be 5 meetings every year to talk about key topics that affect a range of different people. Health and Social Care Managers will go to the meetings. Hold meetings to discuss key topics hosted by local people Stronger links with Neighbourhood Planning and Councils Produce information in visual and easy read formats, including this plan

19 Our Journey to Better Outcomes Transfer rehabilitation service from Liberton Discharge within 72 hours of being considered fit to go home Extra care housing for older people 2015/16 New complex care unit 2016/ / /17 New services in Midlothian Hospital 2017/18 Track progress with our journey to better outcomes map. This will build out as the plan evolves. the right care the right support the right time

20 Give us your voice We d love to hear your thoughts and views on our plan: Does the content make sense to you? Do you like this visual format? Is there anything missing? Anything else you want to add? Contact: Catherine Evans, Public Involvement Coordinator Tom Welsh, Integration Manager

21 Appendix National Health and Wellbeing Outcomes 1. People are able to look after and improve their own health and wellbeing and live in good health for longer 4. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services 2. People including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonably practical, independently and at home or in a homely setting in their community 5. Health and social care services contribute to reducing health inequalities 3. People who use health and social care services have positive experiences of those services, and have their dignity respected 6. People who provide unpaid care are supported to look after their own health and wellbeing, including reducing any negative impact of their caring role on their own health and wellbeing 7. People who use health and social care services are safe from harm 8. People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide 9. Resources are used effectively and efficiently in the provision of health and social care services

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