Intermediate Care – Fife

Examples of Practice

The aim of establishing ICASS in Fife was to transform community services by bringing together uni-disciplinary teams to utilise fully resources available in line with demand, and to coordinate care through a single point of access (SPOA). It contributes to our commitment to ensure the closer integration of the range of community services under one system.

It aims to improve quality of care and outcomes for older people whilst allowing them to remain independent within their own homes or communities, provides alternatives to hospital admission, reduces the number requiring long term institutional care, reduces length of stay for those who require a hospital admission.  It aims to address the following:

  • Moving from an inpatient model of care to a robust community based model of care involving older people and their carers and families in care planning
  • Bringing together teams to make more efficient use of resources to meet the needs/demands of the increasingly elderly population
  • To provide a single point of access
  • To provide alternatives to hospital admission
  • To reduce length of stay if an admission is necessary
  • To provide assessment and care in the person’s own home or a homely setting
  • To achieve and sustain maximum potential and independence; and
  • To reduce numbers going into long term institutional care.

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Teviot Project

Examples of Practice

The need to challenge current service delivery and to identify areas of improvement to support earlier discharge from inpatient setting to patients own home/homely setting.

This project aimed to test a new model of community based Allied Health Professional (AHP) provision in the Teviot Locality.  The service is designed to support: earlier discharge from acute settings for stroke and fractured neck of femur patients; earlier discharge from community in-patient beds and the avoidance of unnecessary admissions and re-admissions for patients who require physiotherapy and/or occupational therapy intervention.

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Hospital In Reach

Examples of Practice

  • Identifying Midlothian residents that have been admitted to one of the Edinburgh hospitals.
  • Outcomes focussed assessment to determine if they can facilitate an earlier discharge either to Highbank Intermediate Care facility or home with a package of care and/or rehab.
  • Assessment to facilitate earlier discharge to care homes where appropriate.

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Delivering Choice Programme

Examples of Practice

To identify palliative and end of life care needs in Argyll and Bute –

  1. To understand the gaps in the delivery of palliative and end of life care
  2. To develop and support cross partnership working in the area of palliative and end of life care.
  3. To develop new services and initiatives to improve palliative and end of life care

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