Intermediate Care – Fife

Examples of Practice

The aim of establishing ICASS in Fife was to transform community services by bringing together uni-disciplinary teams to utilise fully resources available in line with demand, and to coordinate care through a single point of access (SPOA). It contributes to our commitment to ensure the closer integration of the range of community services under one system.

It aims to improve quality of care and outcomes for older people whilst allowing them to remain independent within their own homes or communities, provides alternatives to hospital admission, reduces the number requiring long term institutional care, reduces length of stay for those who require a hospital admission.  It aims to address the following:

  • Moving from an inpatient model of care to a robust community based model of care involving older people and their carers and families in care planning
  • Bringing together teams to make more efficient use of resources to meet the needs/demands of the increasingly elderly population
  • To provide a single point of access
  • To provide alternatives to hospital admission
  • To reduce length of stay if an admission is necessary
  • To provide assessment and care in the person’s own home or a homely setting
  • To achieve and sustain maximum potential and independence; and
  • To reduce numbers going into long term institutional care.

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Delivering Choice Programme

Examples of Practice

To identify palliative and end of life care needs in Argyll and Bute –

  1. To understand the gaps in the delivery of palliative and end of life care
  2. To develop and support cross partnership working in the area of palliative and end of life care.
  3. To develop new services and initiatives to improve palliative and end of life care

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Workforce Development – Dementia and Palliative Care

Examples of Practice

Reducing levels of delayed discharge from hospital by providing specialist care at home or in care homes in the community; avoiding unnecessary admissions to hospital by supporting community-based alternatives to hospital admission; expanding and promoting choices for older people in anticipatory care planning; ensuring staff have the right skills to be able to appropriately and effectively support people at home.

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Marie Curie Health & Personal Care Assistants

Examples of Practice

To deliver an integrated approach to support patients and their carers sustain care in their own home for end of life care.

Figures produced by ISD show that those in the final year of life accounted for around 30% of all bed days.  While 50% of patients continue to die in hospital, Marie Curie can evidence that 98% of those cared for at home with Marie Curie input can be sustained at home.

P&K CHP currently deliver 3 Marie Curie shifts per week for each patient assessed to be in the last 12 weeks of life regardless of diagnosis.  Evidence from the last 2 years data shows that existing and predicted increasing demand for enhanced services is no longer sustainable.

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