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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Self Management Support

Examples of Practice

This test of change is to determine

  • if with initial support individuals can learn to self manage their condition
  • if by self managing, individuals have increased wellbeing
  • by self management, individuals self report a decrease in formal medical and social support
  • if there is a reduction in the prescribing of anti- anxiety drugs.

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Home Care Re-ablement

Examples of Practice

Users of the previous traditional home care service received a service that operated in a culture of ‘doing things for’ people that reinforced deficits and increased dependency. This ‘locked in’ resources with people who had the potential to improve their confidence, self esteem and independence while demand for the service was increasing because of the growing numbers of older people. In addition, there were financial pressures on the local authority.

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Befriending Plus

Examples of Practice

Older people are increasingly experiencing social isolation. Statutory services are unable to provide the one-to-one social aspect that a volunteer can provide which is a proven intervention in improving people’s mental health and wellbeing, reducing social isolation and providing associated health benefits of people re-engaging with their community through support.

Contact with a volunteer on a regular basis provides the opportunity for observation of a befriendee’s wellbeing and allows interventions to be explored or offered before the situation deteriorates to crisis level.

We believe that Befriending Plus complements the changing emphasis of statutory service provision towards re-ablement and helps to reduce the high demand on health and social care services.

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