RESHAPING CARE FOR OLDER PEOPLE
Val Hatch NHS Fife, Martin Thom Social Work and Kenny Murphy Fife Voluntary Action
INTRODUCTION
INTERMEDIATE CARE & SUPPORT SERVICES
Intermediate Care
COMPONENT PARTS
• Hospital at Home
• Intermediate Care
• Home Care
Intermediate Care Framework in
Fife also includes
• Independent Sector Beds
• Alan McLure / Valley House
Hospital at Home
Patient/Service User
Single Point of Access for hospital
discharge being developed thought
the discharge hub at Victoria
Hospital
Activity
Net Budget £2.205M
HOSPITAL @ HOME
A community clinical assessment and
care model that support people at home
as an alternative to hospital admission
Community Life
Assessment
& Clinical Care
Patient
Provision
Implementation Plan
DWF
KLM
GNEF
Total New Patients
Ave LoS
Age Criteria
April 2012
July 2013
Sept/Oct 2013
5-8 days
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
Activity
INTERMEDIATE CARE TEAMS
Community
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
Care At Home
Patient/Service User
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
What we have done
2 Social Work Service Reablement Occupational
Therapists, 6 NHS Fife Patient Flow
Co-Cordinators and 1 Administrative Support
DISCHARGE HUB
System
Community
Service User
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)
Activity
Net Budget £18M
Current overspend of £3.156M
HOME CARE
Service User
Developing 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.
System
Community
Service User
Customer Satisfaction
• Home care (November
2012) 91% satisfied
• Telecare (February 2013)
93% satisfied
• Community Alarms
(February 2013) 96%
satisfied
•
•
•
•
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.
What have we done
2 local Authority Homes (14 beds)
3 Independent Sector Homes (20 beds)
INTERMEDIATE CARE 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.
System
Community
Service User
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.*
Investment: £70.542m
RESHAPING CARE
System
Community
Service User
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.
LIFE LONG LIVING
11 Projects
System
Community
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
Service User
Change Fund Investment £500,00