What was the issue you were addressing or working on?
Systems & processes are not always conducive to good communication, anticipatory planning and integrated working. This is particularly evident for people with complex needs requiring a multi agency, multi disciplinary approach who may not able to advocate for themselves.
What you did?
In order to support individuals to remain in their home following discharge from acute care an integrated approach involving Primary Healthcare Team/Local Authority/Secondary care and family members/informal carers is being used. Starting from the pre-discharge case conference, joint planning and assessment is being used to co-ordinate the return home and support tailored care to avoid care home admission.
Examples from one case include:
Assessment & care management team met with senior nurse adult community nursing to scope potential for successful trial period at home for the lady.
Subsequent involvement of GP, district nursing both day & OOH teams, Homecare reablement team, Community Alarms service, GG&C Anticoagulant Service.
Initial home assessment over a number of weeks to assess patterns of need / behaviour to establish how best to support patient across 24 hours and minimise risk for example facilitating safe use of medicines.
Reablement in Inverclyde is used as a conduit for problem solving in complex discharges and has been fully funded from change fund.
Staff have been given autonomy to create processes and relationships which support joint working.
What were the outcomes - benefits or otherwise?
There have been some successful outcomes for patients who would in the past have been admitted to long term care and in the example above, the lady still maintains her tenancy within very sheltered housing complex (since Dec 2012).
Patient and family pleased with integrated / joint approach to service provision.
Some challenges remain in and around communication / collaboration with services not managed by the CHCP.
A more collaborative approach to the administration of medicines in the home setting particularly potentially harmful medicines such as Warfarin and this will be explored via the change fund pharmacy technician post.
The principles of joint planning and delivery of care will be built upon by the development of integrated frontline teams (including DNs, care managers, AHPs) across the coming months.
Contacts - to find out more
Christine Hennan, 01475 506028, Christine.firstname.lastname@example.org