Extended Community Care Team in Bute

Examples of Practice

To prevent unnecessary admission to hospital and facilitate early discharge from hospital;  to shift the balance of care to home and homely settings.

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Timely adaptations including housing adaptations

Examples of Practice

Waiting times for Occupational Therapy (OT) assessment were increasing and consultation with OT staff across Angus identified that they were spending a significant amount of their time in the office dealing with general OT enquiries, taking and prioritising referrals and dealing with service user complaints about delays. This prevented staff from seeing service users and arranging essential equipment and adaptations. The process for dealing with some minor adaptations had also been identified as cumbersome and time consuming for staff and resulted in delays in the adaptation being put in place.

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Telecare

Examples of Practice

The initiative was supported by the Partnership which wished to reduce levels of delayed discharge from hospital by eliminating or minimising waiting times for telecare installation to support older people living at home with a care package.

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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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Duty and Response Team

Examples of Practice

Prior to the establishment of the Duty and Response Team, there was no community rehabilitation team and social care and health elements of support operated independently, albeit collaboratively with one another. This still meant duplication of information sharing and assessment processes for older people requiring the service. The Change Fund enabled the addition of Physiotherapy and Occupational therapy professionals to join the Adult Wellbeing duty and response team to form a multidisciplinary duty, response and rehabilitation team.

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