Very few patients had an anticipatory care plan in place should they become unwell and none had a plan should their informal carer become unwell or unavailable. There were often separate plans in both Health and Social Care and sometimes access to the required information out of hours was difficult or the information just unknown, potentially resulting in short term care home admissions and avoidable hospital admissions.
Action learning (AL) is an approach that is widely recognised as having great value for leaders and managers who are working with complex issues. Participants do not simply discuss theoretical issues, but bring real challenges to the group, to first understand them better and then to find how to take skilful action. AL fits with both action research and the experimental approaches required for complex issues, as well as with PDSA (Plan, Do, Study, Act) frameworks for taking proactive improvement initiatives.
A learning set is a group of eight to ten key members who agree to meet for an agreed number of facilitated sessions to reflect on how and what they are doing in the face of complex challenges. These meetings are confidential and require a willingness to question their assumptions. The aim is learning not performance management and, facilitated by an external third party, focuses on tackling the real work issues of the participants. It involves reflection, analysis and taking specific action. Group learning involves drawing from each other’s issues and action plans for what are often similar or shared problems.
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.