ICF Anticipatory Care
Workstream
Paul Adams
Head of Primary Care & Community Services
NW Locality, Glasgow HSCP
&
Workstream Lead for Anticipatory Care
“It pays to plan ahead. It wasn't raining when Noah built the ark.”
Anon
7. Managed Medication
(acute Interface)
•Capture need in AC plan
•Ensure good medicine management (avoid
illness and admission)
•Identify people in hospital and promote medicine
support on discharge
•Raise awareness in acute sites
6. Dementia Strategy
•Develop vision for Glasgow
•Ensure consistent approach
•Ensure clear/consistent information
5. Dementia P.D.S
•Create Personal/AC Plan
•Establish preferred approach
•Provide consistent approach
•Provide training/awareness
•Improve quality of life
•Reduce time in hospital
•Signpost
•Support person and carer
8.
Fast Track Palliative
Care Service
•
•
Improve quality of life (and death)
Support choice/preferred place of
death
Avoid hospital admission and
reduce bed delays
Use Personal /AC Plan (“my
thinking ahead”
•
•
ICF Anticipatory Care
Workstream
(8 Projects)
“Proactive Care”
1. AC Framework Model
•Create recognised personal plan
•Use standard “Glasgow” approach
•Empower patient/clients
•Raise staff awareness
•Share information
•Connect services
•Prevent admission
2. SPoA/Admin
•Improve access to nursing care
•Improve response times
•Free Practitioner time to enable
proactive AC
4. Community Respiratory Service
3. Glasgow Falls Model
•Create AC Plan
•Improve self-management for people with COPD
•Refine care pathways across primary/secondary
care
•Provide fast response to avoid admission
•Supported discharge (shortened stay in hospital)
•Share information
•Signpost to other services
•Create AC Plan
•Earlier intervention/rehab
•Identification of associated issues (eg
equipment/housing)
•Reduce risk of further falls/admission to
hospital
•Advice Exercise, Self Management
Success to Date
•
Effective partnership working, e.g. with Marie Curie, Alzheimers Scotland, Cordia
Home Care.
•
Glasgow Palliative Care Fast Track Service available across the city from October
with potential to support almost 500 patients at home this year; avoiding around
15,000 bed days in hospital
•
Glasgow Dementia Strategy out for consultation with an expectation of complete
strategy document and launch Jan/Feb 2016
•
Dementia Post Diagnostic Support (PDS) evaluation will complete at end of 2015 and
will inform Glasgow’s future approach.
•
Respiratory Service will cover all Glasgow by December & expects to receive around
75-100 referrals/month. Of these, 40% will be Urgent, 40% early discharge and 20%
supported self-management. 95% of urgent/”at risk of admission” will be seen within
24 hours.
•
Existing Falls response pathways have been reviewed and a screening form tested.
Good Practice
• Emergence of AC plans across projects
• Sharing learning at local and national events
• Awareness raising of managed medication in acute hospitals.
• Application of evidence-based interventions.
• Utilising technology to release practitioner time which will be
focussed on engaging in anticipatory care discussions and personal
planning.
• Working with Evaluation Support Scotland to ensure 3rd sector
contribution is visible.
Challenges
• SPoA infrastructure delays - testing from early 2016
• Recruitment timescales
• New hospital (work with managed medicines)
• Keeping focus (e.g. clarity about what care groups/professions need
to be testing/adopting ACPs then gradually roll out).
• Sharing information across multiple platforms
• Finance & sustainability
Service extracts – Fast Track
Service extracts – Respiratory
1.0 WTE Band 7
6.0 WTE Band 6
1.0 WTE Band 5
3.0 WTE Band 6
1.4 WTE Band 7
1.0 WTE Band 6
0.5 WTE Band 5
1.0 WTE Band 6
1.5 WTE Band 3
1.0 WTE Band 3
½ day fortnightly
Total over 20 people
Team Lead
Physiotherapists
Physiotherapist –rot.
Respiratory Nurses
Pharmacist
Occupational Therapist
Occupational Therapist
Dietician
Rehab Support Worker
Team Secretary
Respiratory Consultant (Acute)
URL: www.alzscot.org/campaigns/glasgow_city_dementia_strategy
“Organizing is what you do before you do something, so that when
you do it, it is not all mixed up.”
A.A. Milne