Community Ward Service

Examples of Practice

Reducing emergency admissions for people with long term conditions (with focus on COPD, Heart Failure, Diabetes, Recurrent UTI/Infection & Falls).

Read more

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

Read more

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

Read more

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.

Read more

Future of Care at Home Career

Examples of Practice

Provide a workforce capable of meeting the demands of increased anticipatory care activity within homes or homely settings by addressing the key priorities of the workforce development agenda.  These priorities are:

  • Career Pathways and training
  • Workforce integration
  • Asset and infrastructure development
  • Service planning

Read more