Anticipatory Care Planning

Examples of Practice

Identifying older people at risk of admission/ readmission to hospital. High rates of multi-morbidity in older population. Evidence suggests that ‘anticipatory’ discussions with older people with long term conditions regarding their future care  choices can reduce avoidable admissions

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Dementia Advisory Clinic Co-production Model

Examples of Practice

East Dunbartonshire has the highest ratio of older people in Scotland. The percentage of population with dementia in the area is also greater than the national average and is expected to increase even further.

The clinic model contributes to a more efficient use of existing services through enhanced co-ordination of the existing resources of all of the partner organisations. They deliver flexibly and sensitively the type of advice and support that people with dementia have told us they need.

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Modernising Community Nursing

Examples of Practice

The Western Isles has a changing demographic with a higher population of older people than the Scottish average, this coupled with an ageing workforce and outward migration of young people has brought into focus the need  to continue with the modernisation of our acute services and deliver more services closer to communities.

In conducting a review of unscheduled care the National Dashboard summarises NHS Western Isles performance as:

  • A&E attendances -7% WI v.+ 1%  Scotland
  • A&E admissions : -6% WI v. +10% Scotland
  • A&E admissions as % of non-routine discharges: 65% WI v. 71% Scotland
  • Ave. Stay Emergency stay (WIH ) : 5 days less than Q4 2011
  • Acute beds: down 12% WI v. 2% Scotland
  • Acute Beds per 1,000 acute discharges: 66 WI v. 44 Scotland
  • Acute emergency discharges: -2.5% WI v. +2% Scotland
  • Acute non-emergency discharges: -2.5% WI v. +2.6% Scotland
  • Beds lost to DDs: 7 WI

In summary for latest period WI has reducing lengths of stay reflecting reduced bed numbers and reduced acute admissions (both emergency and elective) in turn reflecting reduced A&E attendances and onward admissions from A&E.  Some of this contrary to Scottish trend (See above list) but remain above average in comparison to Scottish levels for few areas eg. ALoS and Number of beds relative to number of patients. 

NHS Western Isles approach is integrating all of our Unscheduled Care activity under a single work stream, taking a whole system approach and working closely with service users, Local Authority partners and Third Sector providers. This work is ongoing.

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DALLAS / Living it Up Project Manager

Examples of Practice

Effective engagement with the target population across the Western Isles is crucial for the project’s success, enabling the local team to:

  • gauge the current level of interest in use of technology
  • capture information on concerns, fears and issues contributing towards reluctance to use technology that will inform the design and delivery models of services
  • establish a dialogue on the use of technology in relation to health and quality of life
  • identify and understand opportunities for future use
  • identify how LiU can support local service improvements & ensure that these are informed by local needs and issues

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See and Treat

Examples of Practice

Falls are the most common call received by the Scottish Ambulance Service in Aberdeen, with a mid-morning peak.   The purpose of this project was to maximise the number of Older People who can be supported to remain at home, following a fall.  This is intended to significantly reduce the number of unnecessary hospital admissions for older people.

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