Embedding Personal Outcomes in Practice

Examples of Practice

Embedding Personal Outcomes workshops using the sound slides from Sliding Doors that were developed by SSSC and NES.  The sessions used real life actors from Strange Theatre using the scripts that were written by Forum Interactive for SSSC and NES.  The main objective of the workshops has been to give staff time and space to consider the effect of their actions at ‘turning points’ in peoples’ lives and to consider how they may step back and avoid ‘fixing’ and really listen to the outcomes that individuals want to achieve.

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COMPASS

Examples of Practice

The objectives of COMPASS include:

  • To improve the identification of older people in the community at risk of escalation / hospital admission
  • To facilitate and provide proactive case management for those at risk of admission by the most appropriate service
  • To prevent the emergency admission of patients to hospital by facilitating and providing timely access to alternatives within domiciliary, outpatient, Day Hospital and inpatient settings
  • To facilitate the discharge and prevent later readmission of patients from hospital following a planned or emergency admission
  • To provide a point of contact for GPs to seek advice/ discussion with a Medicine of the Elderly (MoE) consultant, with the aim of reducing emergency hospital admissions where possible and appropriate
  • To conduct comprehensive assessment for patients in a range of settings
  • To improve understanding of, and communication between primary, secondary and social care services, leading to better outcomes for individual patients/ service users
  • To identify areas for further improvement, collaboration and joint working and to develop a vision for future ways of working, including a ‘virtual ward’ ‘hospital at home’ model

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Hospital at Home

Examples of Practice

The challenges included shifting from institutional based care to care at home or a homely setting, the need for quicker assessment and care plan coordination and formulation in a more homely setting taking into account the person’s conditions and home situation instead of needs and support being assessed in a ward setting.

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Step Up Step Down Beds

Examples of Practice

An agreement was drawn up with three Care Homes within the Kilmarnock area for one room in each home for the purpose of rehabilitation.  The steps up step down beds (as now named) have been purchased by local authority and change fund money.  They will offer an alternative to hospital admission or an early supported discharge when the patient/service users can not be supported at home but are not unwell enough to stay in hospital.  The care homes have embraced this service working closely with all concerned to ensure that the agreed outcomes are met.

Initially getting appropriate referrals was difficult as after assessment, we found we were able support the majority of service users/patients within their own home. At present we are working with the local GPS and Geriatricians to build up trust and confidence in this service so they will refer more complex cases that require the twenty four hour support from the team within the care home.

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