Homecare Redesign

Examples of Practice

Falkirk Council Home Care Service provides care to approximately 1,600 in house service users and manages the care of approximately 300 + external agency only and in-house plus external agency and or voluntary provider service users.

The traditional model of management for this service had been to appoint home care managers on a geographical basis to manage the whole range of services to be provided. Whilst this was acceptable 15 years ago with the changes to care provision, increased volume of care at home services and the changing ethos of how we provide services, e.g. re-ablement, use of private providers etc. the traditional model was outdated, no longer met the needs of the service users and was preventing the capacity of managers to provide the high quality of care services which we aim to provide.

As part of our self evaluation exercise we highlighted the need to diversify our management arrangements and specifically aim to target the effective splitting of the patch home care manager’s role into three specialism’s. These will be long term service provision within a geographical patch, resource management of agency providers, shopping meals and laundry services and our 24/7 service providing specialist re-hab at home, crisis care and to move into a more involved relationship with facilitating more appropriate and timely discharge of patients as well as preventing hospital admission by extending the remit of our rapid response services and working closer with our colleagues in Reach.

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Housing with Care Reablement Service, Tygetshaugh Court, Dunipace, Falkirk

Examples of Practice

The aim of the HWCRS is to:

  • transfer appropriate people to the HWCRS (e.g. those who meet the agreed criteria)
  • work with and encourage service users to regain their level of function with regards to mobility, personal care and kitchen tasks resulting in an increase in confidence and independent living for the service user
  • educate the informal care/family regarding the re-ablement approach to care
  • encourage socialisation and taking part in mainstream HWC activities

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Intermediate/Reablement Care Beds

Examples of Practice

The facility was established to pilot a model that would:

  • prevent unnecessary permanent admission to residential care
  • prevent unnecessary admission to hospital.
  • facilitate discharge from hospital and contribute to managing delays in discharge from acute or community hospitals.
  • deliver support to ensure a safe and full re-integration into the Service Users home and local community.
  • assist Service Users’ in setting and achieving their planned goals, placing the emphasis on the Service Users needs. Goals will be set with the service users and reviewed weekly or as required throughout their stay
  • support Service Users to regain and maintain daily living skills.
  • support carers in their role during a person’s stay in the unit and after the assessment period is complete.
  • respond quickly and flexibly to the changing needs of the Service Users to support their return home.

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Carers Support Service – Locality Workers

Examples of Practice

Referrals to the Angus Carers Centre from health providers were low.  This is a key source of identification of carers where support can be provided to allow them to continue to care and have a life outside of caring.

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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

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