REACH (Rehabilitation and Enablement in Aberdeenshire Care at Home) – Early Implementers

Examples of Practice

To test and develop a model for a rehabilitation and enablement that would prevent avoidable hospital admission, facilitate early hospital discharge to home, and enable people to develop confidence, re-learn daily living skills following illness that are consistent with their personal goals and sustain independent living, working towards supported self management.

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Hospital Discharge Liaison – Mrs W’s Story

Examples of Practice

A concerned neighbour contacted Services about Mrs W, aged 90 living in Eastwood Area. A visit was conducted, identifying Mrs W as being in an extremely fragile state, physically and cognitively.  Her house was found to be dirty and difficult to access due to clutter in rooms and passageways.  Kitchen flooring was a trip hazard; oven, microwave and washing machine were dirty and broken.  She presented as delusional and unable to convey appropriate self determination as to her presenting circumstances.  Her GP was called with regards to an emergency health assessment.  It was determined that she was at such a high level of risk that she was detained in Hospital.  Mrs W spent 16 weeks in Hospital.  Made good health progress, and was supported through good discharge planning to return home at the earliest appropriate time.

Mrs W was identified as having complex issues regarding her capacity.  Supporting her to return safely and within Hospital Discharge guidelines to her own home in community from Hospital was considered to be complex.

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Future of Care at Home Career

Examples of Practice

Provide a workforce capable of meeting the demands of increased anticipatory care activity within homes or homely settings by addressing the key priorities of the workforce development agenda.  These priorities are:

  • Career Pathways and training
  • Workforce integration
  • Asset and infrastructure development
  • Service planning

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Extended Psychiatric Nurse Liaison Team For Older People in Acute Care

Examples of Practice

The service aims to promote the understanding of the need for an integrated approach in care of the elderly in acute care.  It demonstrates the impact that psychiatric morbidity can have on physical health and rehabilitation and how joint working with other professional groups can improve the quality of care and outcomes for elderly patients.  It has developed and implemented an acute pathway for people with cognitive impairment entering the acute hospital, and assisted in early identification and diagnosis of dementia by providing specialist assessment and treatment interventions, education and support to patients, staff and carers.

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Enhanced Hospital Discharge

Examples of Practice

The early identification of carers in order to provide information and support before the caring role begins to have a negative impact on the health and wellbeing of the carer.

The aim was to identify carers at the point of hospital discharge, and to provide information and support to the carers of older people in Falkirk at this vital time at the start of their caring journey or when their caring role was changing.

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