Extended Community Care Team in Bute

Examples of Practice

To prevent unnecessary admission to hospital and facilitate early discharge from hospital;  to shift the balance of care to home and homely settings.

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Referrals to Dietetic Service From Care Homes

Examples of Practice

To continue to provide safe, effective person centred care by standardising and improving the quality and appropriateness of referrals for care home residents received into the Department.

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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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Integrated Community Support Teams

Examples of Practice

Consultations with all stakeholders prior to this project had identified key issues:

  • Join staff into one team and provide 24 hr community nursing and home care.
  • Make it a neighbourhood model
  • Use existing knowledge, skills and practices.
  • Build in confidence and resilience within the local workforce
  • Retain GPs as the responsible medical officer

The principles mainly being to:

  • Provide effective, person centred support to enable people to remain safely at home for as long as possible
  • Support the person to return home as soon as possible if admitted to hospital
  • Support older people with complex health and social care needs to have their community care assessments carried out in their own home if possible

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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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