See and Treat

Examples of Practice

Falls are the most common call received by the Scottish Ambulance Service in Aberdeen, with a mid-morning peak.   The purpose of this project was to maximise the number of Older People who can be supported to remain at home, following a fall.  This is intended to significantly reduce the number of unnecessary hospital admissions for older people.

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Reablement and Crisis Care

Examples of Practice

The re ablement and crisis care service has re-focused its activity to intervene earlier and promote the independence of older people. The new service design has delivered the following improvements

  • 24/7 response to any crisis
  • Fast Track provision of technology and equipment
  • Single point of contact for responding to falls
  • Falls prevention programme
  • Respite for Carers
  • Intensive Re-ablement Programme, building personal resilience
  • Improved alignment of social and health care staff, making better use of resources

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Pharmaceutical Care

Examples of Practice

The Borders Pharmaceutical Care Project aims to prevent avoidable medication related hospital admissions (e.g. falls, adverse drug reactions), optimise medicines use, reduce the number of potentially inappropriate medicines prescribed, enhance integrated working between Health and Social Care to enable safe medicine administration, and support others to identify patients at high risk of medication related adverse events.

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Access to Comprehensive Geriatric Assessment in the Community

Examples of Practice

Anticipating patients that are moving towards a health transition because of emerging health issues.

In Moray we monitor daily the number of patients that are over 65yrs, who attend A&E and are subsequently discharged. We used the Change Fund to second a senior nurse practitioner to work alongside a Consultant Geriatrician to follow up the patients who were discharged. Case studies suggest that early intervention of this type has prevented further deterioration or enabled planned interventions removing the unpredictability of an unscheduled admission.

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Palliative Care Training in Care Homes and in the Community

Examples of Practice

To implement ‘Living & Dying Well’ across all settings in Aberdeenshire.  A dedicated Project Manager was appointed to facilitate implementation of Living & Dying Well in Aberdeenshire.  Previous work had focused on Aberdeenshire Care Homes which had been very successful in raising awareness of the identification, assessment and ongoing review of palliative patients using a facilitative, rather than an instructional approach. This had demonstrated that cross boundary working is possible and positive.  There was a need to extend this approach to other primary care, social care, voluntary and independent care settings in order to provide all staff with the confidence they need to carry out effective, person centered palliative care for older people.

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