Nairn Anticipatory Care Planning (ACP) and Integration: A Primary Care Pilot Study Aimed At Reducing Unplanned Hospitalisation

Examples of Practice

The number of people in the UK aged over 65 is growing and is forecast to reach 16.1 million by 2035.  The burden of disease associated with aging will increase as will the demands on health services including end-of-life and palliative care.  The National Confidential Enquiry into Patient Outcome and Death in 2008 found that rather than advanced care planning and palliation taking place, some patients were subjected to excessively active interventions in their last months of life.

The pilot study aimed to ascertain whether using primary and secondary care data to identify patients at risk of hospital admission and agreeing and implementing an Anticipatory Care Plan in this population could help to reduce hospital admission rates.   Anticipatory care planning allows patients to express their wishes for care prior to a sudden deterioration in their health.

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Creating a Well-Designed Living Space for People with Dementia Memory Garden, Drummond Ward, Biggart Hospital

Examples of Practice

Creating a safe and well-designed living space for people with dementia within a general hospital setting.  Such a space is a key part of providing care which can improve physical and mental functions of people with dementia, and regular access to fresh air and exercise, and a quiet space away from others helps individuals in becoming less agitated and distressed.

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Managing the Fallen Uninjured Person

Examples of Practice

The negotiation of each organisation’s contribution to making the pathway work. Developing a pathway that is easy to access and offers the fallen person timely assistance. Promoting and embedding the pathway across all organisations.

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Using Lean methodology to support the improvement of older people’s pathways

Examples of Practice

To improve entire patient pathways in the areas of Medicine of the Elderly, orthopaedic rehabilitation, stroke services and management of acute patients with dementia and delirium.[1]  Specifically to use lean methodology to:

  1. Improve flow to ensure that patients get timely access to the appropriate services
  2. Reduce lengths of stay for older people
  3. Improve health and social care interfaces
  4. Support the rebalancing of care towards care in the community
  5. Improve the management of patients in acute settings with dementia and delirium.

[1] (Care Homes not in scope for the programme.  MoE encompassed community & social care services (except Stroke, GORU & Dementia).

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