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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Community Ward Service

Examples of Practice

Reducing emergency admissions for people with long term conditions (with focus on COPD, Heart Failure, Diabetes, Recurrent UTI/Infection & Falls).

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South Angus Locality Medicine for the Elderly Model

Examples of Practice

The management of frail Angus patients was reliant on hospital admission and prolonged stay to assess and manage acute or often non-acute de compensation to a frail person’s health.  This resulted in high occupancy rates in community hospitals and adverse outcomes for patients such as hospital acquired infection.

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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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Integrated Community Support Teams

Examples of Practice

Consultations with all stakeholders prior to this project had identified key issues:

  • Join staff into one team and provide 24 hr community nursing and home care.
  • Make it a neighbourhood model
  • Use existing knowledge, skills and practices.
  • Build in confidence and resilience within the local workforce
  • Retain GPs as the responsible medical officer

The principles mainly being to:

  • Provide effective, person centred support to enable people to remain safely at home for as long as possible
  • Support the person to return home as soon as possible if admitted to hospital
  • Support older people with complex health and social care needs to have their community care assessments carried out in their own home if possible

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