West Dunbartonshire CHCP recognised that the RCOP agenda offered both opportunities and risks to providers of care. In developing a cohort of managers involved in My Home Life we are attempting to support our Managers to embrace the changes which RCOP will bring and also support them to engage with key decision makers in order that they can help direct the future provision of care in order that it better meets the needs of those receiving care. Whilst promoting the delivery of high quality care.
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.
Previous mapping of the falls pathway had demonstrated that there was no clear systematic approach to the identification and onward referral of those presenting to the A&E department at the local hospital with a fall.
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.
Enhancing Intermediate care pathways and options of care for individuals who are at risk of requiring a care home placement. Particularly those discharged from hospital including those who become or at risk of becoming delayed discharges.