Alternative Housing Models and Intermediate Care

Examples of Practice

Issues the projects addressed were:

  • Supporting people to live more independently in the community for longer, thereby reducing care home admissions
  • Making better use of care services to move away from the rigid model of home carers visiting
  • Working with Registered Social Landlords to bring together the Housing Support function with personal care
  • Filling the gap of reduced social and community based activities as a result of the move from institutional models of care

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Access to Comprehensive Geriatric Assessment in the Community

Examples of Practice

Anticipating patients that are moving towards a health transition because of emerging health issues.

In Moray we monitor daily the number of patients that are over 65yrs, who attend A&E and are subsequently discharged. We used the Change Fund to second a senior nurse practitioner to work alongside a Consultant Geriatrician to follow up the patients who were discharged. Case studies suggest that early intervention of this type has prevented further deterioration or enabled planned interventions removing the unpredictability of an unscheduled admission.

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Palliative Care Training in Care Homes and in the Community

Examples of Practice

To implement ‘Living & Dying Well’ across all settings in Aberdeenshire.  A dedicated Project Manager was appointed to facilitate implementation of Living & Dying Well in Aberdeenshire.  Previous work had focused on Aberdeenshire Care Homes which had been very successful in raising awareness of the identification, assessment and ongoing review of palliative patients using a facilitative, rather than an instructional approach. This had demonstrated that cross boundary working is possible and positive.  There was a need to extend this approach to other primary care, social care, voluntary and independent care settings in order to provide all staff with the confidence they need to carry out effective, person centered palliative care for older people.

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‘Moving, for independence’

Examples of Practice

  1. Client accommodation was unsuited for older person safe independent living (first floor, no lift, many steps, poor layout)
  2. Person was frightened by thought of moving; family has pressed to ‘go into a home’ – clearly not older person’s preference.
  3. GP confirmed suitable ground floor accommodation meant no need for move to care home or similar
  4. Greatest barrier was older persons fears – how could I manage to move, how can I afford to move, how do I deal with everyone (who?), how do I pack / unpack.  Do I have to give up independence because I am too old to cope.

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Liaison Psychiatry for Older People

Examples of Practice

It was recognised that an increasing number of older people with dementia and/or mental health problems are admitted to acute hospital inpatient settings.  These patients often require additional supports and hospital staff are less able to manage these patients within a busy ward environment.  In addition to increasing staff skills through staff training, often individual patients will highlight specific issues which require a more specialist understanding or assessment.  The project sought to provide this additional support and assessment.

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