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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Teviot Project

Examples of Practice

The need to challenge current service delivery and to identify areas of improvement to support earlier discharge from inpatient setting to patients own home/homely setting.

This project aimed to test a new model of community based Allied Health Professional (AHP) provision in the Teviot Locality.  The service is designed to support: earlier discharge from acute settings for stroke and fractured neck of femur patients; earlier discharge from community in-patient beds and the avoidance of unnecessary admissions and re-admissions for patients who require physiotherapy and/or occupational therapy intervention.

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Hospital In Reach

Examples of Practice

  • Identifying Midlothian residents that have been admitted to one of the Edinburgh hospitals.
  • Outcomes focussed assessment to determine if they can facilitate an earlier discharge either to Highbank Intermediate Care facility or home with a package of care and/or rehab.
  • Assessment to facilitate earlier discharge to care homes where appropriate.

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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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Developing a Reablement approach within day services for older people

Examples of Practice

Work towards policy objectives and strategies, such as:

  • Reshaping Care for Older People (2010)
  • Live Well in Later Life, Edinburgh’s Joint Commissioning Plan (2012-2022)
  • Integration of Health and Social Care
  • Market Shaping Strategy(2013)
  • Personalisation Agenda

to meet the challenge of increasing numbers of older people.  Key objectives of the service are to:

  • Facilitate early discharge from hospital and prevent admission
  • Maximise people’s independence to remain in the community for longer
  • Supporting people to achieve better outcomes
  • Reduce carer stress.

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