Homecare Redesign

Examples of Practice

Falkirk Council Home Care Service provides care to approximately 1,600 in house service users and manages the care of approximately 300 + external agency only and in-house plus external agency and or voluntary provider service users.

The traditional model of management for this service had been to appoint home care managers on a geographical basis to manage the whole range of services to be provided. Whilst this was acceptable 15 years ago with the changes to care provision, increased volume of care at home services and the changing ethos of how we provide services, e.g. re-ablement, use of private providers etc. the traditional model was outdated, no longer met the needs of the service users and was preventing the capacity of managers to provide the high quality of care services which we aim to provide.

As part of our self evaluation exercise we highlighted the need to diversify our management arrangements and specifically aim to target the effective splitting of the patch home care manager’s role into three specialism’s. These will be long term service provision within a geographical patch, resource management of agency providers, shopping meals and laundry services and our 24/7 service providing specialist re-hab at home, crisis care and to move into a more involved relationship with facilitating more appropriate and timely discharge of patients as well as preventing hospital admission by extending the remit of our rapid response services and working closer with our colleagues in Reach.

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Housing with Care Reablement Service, Tygetshaugh Court, Dunipace, Falkirk

Examples of Practice

The aim of the HWCRS is to:

  • transfer appropriate people to the HWCRS (e.g. those who meet the agreed criteria)
  • work with and encourage service users to regain their level of function with regards to mobility, personal care and kitchen tasks resulting in an increase in confidence and independent living for the service user
  • educate the informal care/family regarding the re-ablement approach to care
  • encourage socialisation and taking part in mainstream HWC activities

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South Angus Locality Medicine for the Elderly Model

Examples of Practice

The management of frail Angus patients was reliant on hospital admission and prolonged stay to assess and manage acute or often non-acute de compensation to a frail person’s health.  This resulted in high occupancy rates in community hospitals and adverse outcomes for patients such as hospital acquired infection.

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Pharmacy Hub/IC&ES Service

Examples of Practice

Provide specialist clinical pharmacist resource within the community setting to enhance pharmaceutical care and reduce avoidable hospital admissions due to medicines, and support successful discharge.

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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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