COMPASS

Examples of Practice

The objectives of COMPASS include:

  • To improve the identification of older people in the community at risk of escalation / hospital admission
  • To facilitate and provide proactive case management for those at risk of admission by the most appropriate service
  • To prevent the emergency admission of patients to hospital by facilitating and providing timely access to alternatives within domiciliary, outpatient, Day Hospital and inpatient settings
  • To facilitate the discharge and prevent later readmission of patients from hospital following a planned or emergency admission
  • To provide a point of contact for GPs to seek advice/ discussion with a Medicine of the Elderly (MoE) consultant, with the aim of reducing emergency hospital admissions where possible and appropriate
  • To conduct comprehensive assessment for patients in a range of settings
  • To improve understanding of, and communication between primary, secondary and social care services, leading to better outcomes for individual patients/ service users
  • To identify areas for further improvement, collaboration and joint working and to develop a vision for future ways of working, including a ‘virtual ward’ ‘hospital at home’ model

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Falls Pathway

Examples of Practice

Previous mapping of the falls pathway had demonstrated that there was no clear systematic approach to the identification and onward referral of those presenting to the A&E department at the local hospital with a fall.

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Workforce Development – Dementia and Palliative Care

Examples of Practice

Reducing levels of delayed discharge from hospital by providing specialist care at home or in care homes in the community; avoiding unnecessary admissions to hospital by supporting community-based alternatives to hospital admission; expanding and promoting choices for older people in anticipatory care planning; ensuring staff have the right skills to be able to appropriately and effectively support people at home.

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Step Up Step Down Beds

Examples of Practice

An agreement was drawn up with three Care Homes within the Kilmarnock area for one room in each home for the purpose of rehabilitation.  The steps up step down beds (as now named) have been purchased by local authority and change fund money.  They will offer an alternative to hospital admission or an early supported discharge when the patient/service users can not be supported at home but are not unwell enough to stay in hospital.  The care homes have embraced this service working closely with all concerned to ensure that the agreed outcomes are met.

Initially getting appropriate referrals was difficult as after assessment, we found we were able support the majority of service users/patients within their own home. At present we are working with the local GPS and Geriatricians to build up trust and confidence in this service so they will refer more complex cases that require the twenty four hour support from the team within the care home.

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Intermediate Care Short Term Assessment in Care Ho

Examples of Practice

Enhancing Intermediate care pathways and options of care for individuals who are at risk of requiring a care home placement. Particularly those discharged from hospital including those who become or at risk of becoming delayed discharges.

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