What was the issue you were addressing or working on?
To prevent unnecessary admission to hospital and facilitate early discharge from hospital; to shift the balance of care to home and homely settings.
What you did?
The Extended Community Care team brings together everyone who would provide care – District Nurses, Occupational therapists, Physiotherapists, Social Workers, voluntary sector and private care givers. Most of the team is co-located which aids communication. The initiative was taken forward through Reshaping Care for Older People and as a pathfinder under the Highland Quality Approach.
A single point of access was established through a mobile phone – the Duty Phone -carried by the person on call which is organised on a rota. The person on duty responds to a call within 45 minutes. The ECCT can commission other services directly with care givers, eg arrange a commode, meals and has the contact information for the Duty GP. The Duty Phone number has been given to partner services, initially A&E Department, then extended to the Scottish Ambulance Service, local Care Homes and the Royal Alexander and Inverclyde hospitals.
The A&E Department make contact when a person attends the department but it is considered that they do not need to be admitted, however an assessment is needed to ensure the person can cope at home. The person on duty attends to make the assessment and puts in place any services that are required.
SAS ‘See and Treat’ service contacts the ECCT for an holistic assessment when they are attending someone who does not need to be transferred to hospital, however may need short term support.
Care Homes were included in the service following an incident where a Care Home was unclear about a resident’s Anticipatory Care Plan and contacted NHS24. The ECCT could have provided support and contacted the duty GP.
The Royal Alexander and Inverclyde Hospitals contact the ECCT for discharges where an assessment for home is needed. The Team can commission any services and contact carers.
A community nurse noticed that a gentleman she visited was a bit low. He is a diabetic and uses a wheelchair. He explained that he was fed up with the same items of shopping every week. He described that he wrote out a list for his carer and they did the shopping; and that he would like to be able to see what is on offer and to choose the items. The nurse discussed this with the Red Cross staff who is part of the ECCT and co-located and they indicated that there was a potential solution. They contacted Interloch based in Dunoon, who operate a number of wheelchair accessible vehicles and provide door to door transport for people who need support. They also contacted the local Co-Operative Supermarket who were very happy to provide a member of staff to go round the store with the gentleman and help him shop. They also arranged for delivery of his shopping to his home. This arrangement is now in place for every Friday. The gentleman now looks forward to a Friday, he meets with others on the shopping trip and chooses his own items.
What were the outcomes - benefits or otherwise?
A crucial resource in the ECCT are the Healthcare Assistants who form the enablement team. They are trained in physiotherapy exercise and putting in hoists and equipment. They provide help at home to facilitate discharge, eg following surgery for a fractured hip they can support exercise at home rather than in hospital. The enablement approach provides an assessment at home, setting of goals and provides 12 weeks of support. This person centred approach has been found to avoid the need for full care packages as the support is tailored to the person’s needs and choice.
Prior to Bute being the pilot site/pathfinder we had 31 beds in the medicine for the elderly and 16 acute hospital beds. There has been a reduction of approximately 34 beds in Bute.