Integrated Day Services
Audrey Brogan
Service Co-Ordinator
Coatbridge
Research
• Long waiting lists for – NLC day care
• Day hospitals –holding on to people as there
was no where else they could go.
• Many older people in day care for years
• Almost 30% coming from sheltered housing
complexes
• Local lunch clubs closing
Waiting Lists
•
•
•
•
•
What did they do now with their day?
What did their family and friends do?
What did they want to do?
What stopped them doing this?
Where could these activities happen?
Findings
•
•
•
•
•
People needed information
Some had lost confidence
Some needed practical support to get to places
Transport was a big issue
No one said - day care
The New Model
• Develop an integrated day service targeting
those older people with more complex needs
• Develop a community network of alternative
options :
- information system
- locality link officers
Integrated Day Service
•
•
•
•
•
Day Services Social Work
Day Hospital Mental Health
Day Hospital Frail Elderly
Linked key professionals
Locality Planning Group
Locality Planning Group
• Case discussions
• Access to a range of services
• Identifying people who require care
management
• Highlighting developments required in the
community
• Supporting the community network
• Joint training / shadowing
The Community Network
• Sheltered housing complexes
•
•
•
•
•
•
•
Lunch clubs
Community halls
Church halls
Leisure services
Community education
Local artists/activity libraries
Voluntary organisations
Role of LLO
•
•
•
•
•
•
•
•
•
Meet Service User
Support case co-ordination
Advise Of Possible Local Community Resources
Arrange To Accompany Service User To Initial
Visits
Advise On Transport If Required
Income check
Support volunteers
Support Sheltered Housing Wardens
Feedback to Referred
Sinclair Day Service
25 Places available each day
15 Core Places
5 Floating Places
5 Ring Fenced Place
Satellite service East Stewart Gardens
Access to Services
• Holistic Assessment:- C.C.A. or S.S.A.
• Referrer to Present Case to Locality Planning
Group
• Eligibility Criteria for Day Services
• If Eligibility Criteria Not Met, Referral Can Be
Considered For Locality Link Officer For Day
Opportunities
• Integrated Service Targeted at People With
Complex Care Needs
Ring Fenced Places
• Full Mental Health Assessment
• Physical Screening Tests i.e. Bloods, E.C.G.,
Blood Pressure etc.
• Treatment Groups i.e. Anxiety Management,
Depression Education & Counselling etc.
• Medication Monitoring
• Therapeutic Group Activities i.e. Relaxation
Therapy, Music Therapy, Health Promotion
(Sleep Awareness, Bereavement & Nutrition etc)
• Multi-Agency Reviews
Floating/Core Places
•
•
•
•
•
•
•
•
Ongoing Assessment Of Needs
Ultimately Case Management
Implementation Of Needs Identified In Care Plan
Emotional & Physical Support
Therapeutic Activities Offered
Independence Promoted
Frequent Reviews
Multi-Agency Liaison
Integrated Working
•
•
•
•
•
Joint Groups
Cross Referral
Regular Planned Meetings
Ad-hoc Information Sharing
Effective Understanding Of Each Agencies Role
Benefits
•
•
•
•
•
2 Services Integrated
Frail Elderly Day Hospital On-Site
Better Communication Between Services
Quicker Access To Services
Shared Skills & Knowledge
Case Example
 Mrs.B was referred to the LPG by the Consultant Psychiatrist.
 Various psychiatric admissions to hospital due to depression and
anxiety. Had not been outdoors for long periods due to this.
 Mental Health was stabilised as much as possible. Husband could not
leave Mrs.B at home alone due to her anxiety.
 Outcome gradual discharge from ring fenced place to floating place at
SIDS, 2 days each week.
 Input from LLO with view to decreasing days at SIDS and link to
community groups.
 Now at two community groups each week
 Secretary of community group committee
 One admission to hospital in 4 years
Review of Pilot Service
Care Reviews
Questionnaires
Service User Meetings
Creative Meetings ‘My Perfect Day’
Talking Points
Talking Mats
Findings
•
•
•
•
•
•
•
•
•
•
•
•
Positive feedback from carers and service users
Positive outcomes for carers and service users
Decrease in hospital admissions
One stop shop
Early intervention to avoid unnecessary hospital admissions
Decrease in admissions to long term care
Support to appropriate admissions to hospital
Increase in number of people living at home
People using service extensive support needs.
Growth in number of community groups and those attending
Still some people isolated at home but don’t meet criteria for IDS.
Communication with NHSL acute services limited
Findings continued
•
•
•
•
•
•
•
Staff team positive about their role
Staff team more knowledge of linked professionals
Staff practise extended
Job evaluation outcome positive for staff
Staff access to both NHSL and NLC training sessions.
Staff motivated by the changes and developments
Staff motivated by the feedback from people who use the
service and their carers.
• Staff positive about their roles in shaping and developing
the service.
Developments
•
•
•
•
•
•
•
•
•
•
•
Review of transport system
Extensive needs of service users 1-7 ratio inadequate
Care co-ordination role more extensive
2 registered nurses
Scalamobile and Stairmatic use and training
Podiatry support
Inhouse training in acute hospitals re IDS
Locality Support Workers Needed
Improve links with Housing services
Review job descriptions and grading of support staff
Further develop knowledge of service at acute hospitals
Day Service Today
•One day service in each town
•No waiting times for access
•LLO referral to first visit one week
•No waiting time for AHP
•Access to home care immediate
•Flexible service as needs change
•Limited admissions to long term care
•Carers support group
•Memory clinic referrals to first access two weeks
•Mental health assessment no waiting times
•Various care homes closed in North Lanarkshire
•OAP beds free