Anticipatory Care Plans

Examples of Practice

This project focused on the implementation of Anticipatory Care Planning within all care homes in Lanarkshire and with the Community Nursing Services. This involved updating the ACP documentation, identifying ACP champions within care homes and community nursing and an intensive programme of education to ensure sustainability of the approach and to ensure preferred wishes for care are met.

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Homecare Reablement

Examples of Practice

  • The reablement approach in homecare offers support and encouragement to individuals to empower them to help themselves and so increase their independence. It supports individuals ‘to do’ rather than ‘doing to’ or ‘doing for’.
  • Goal setting and review of outcomes achieved are central to the reablement ethos. This means that we work with individuals and their carers to establish what tasks they want to gain confidence in doing or relearn particular skills. By engaging with individuals around an agenda of what they can do and what they would like to do we can develop short term interventions which support them to achieve these goals. These are often around basic daily living skills such as dressing, meal preparation and mobility. It is not uncommon for an individual to have lost confidence around their ability to carry out certain tasks after spending time in hospital.
  • Our traditional home care approach has been to assess people around what they no longer can do and provide a service to meet these deficiencies.  As a result services are embedded into people’s lives, often for length periods of time.  While this is perfectly acceptable for a number of people who suffer from severe and complex conditions it has the potential to create a dependency for people who may have had the potential to relearn or regain skills. Reablement focuses on this potential and research suggests that many people who would have received a traditional service leading to risks of dependency can eventually become more confident and lead fulfilling lives when they regain lost skills.

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Medicines Management

Examples of Practice

  • The pro-active identification and assessment of people at a high risk of experiencing an adverse drug reaction leading to hospital admission / re-admission, otherwise known as a polypharmacy medication review.
  • Supported by improving communications and information transfer between hospitals and primary care with regards to medication.

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Care at Home Pharmacy Team

Examples of Practice

The increased number of older people living at home with one or more long term condition means there is increased risk of errors with medication. This has been identified as a risk for emergency admission to hospital. These older people are not a group who would routinely receive a review.   Post Hospital Discharge a ‘transition’ time for many older people was originally targeted with the service now being available for all Care at Home clients.

Additional support to vulnerable older people to manage their medications can avoid emergency admission to hospital.

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