Carers Support Service – Locality Workers

Examples of Practice

Referrals to the Angus Carers Centre from health providers were low.  This is a key source of identification of carers where support can be provided to allow them to continue to care and have a life outside of caring.

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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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Homecare Overnight Service

Examples of Practice

The complexity of people with care needs has increased over recent years.  The service means that people with high level needs can be supported at home with care delivered overnight.  Previously this was only possible in a residential or hospital setting.  Prior to the investment from the Change Fund there were two Overnight teams.  The investment from the Change Fund allowed another three teams to be established.  This has allowed people to move home from hospital, or remain at home, whereas previously a move away from home would be the only feasible outcome for meeting their needs.  In some cases the requirement for care overnight was the only stumbling block to meaning someone could be cared for in their own home.

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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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