What was the issue you were addressing or working on?
An agreement was drawn up with three Care Homes within the Kilmarnock area for one room in each home for the purpose of rehabilitation. The steps up step down beds (as now named) have been purchased by local authority and change fund money. They will offer an alternative to hospital admission or an early supported discharge when the patient/service users can not be supported at home but are not unwell enough to stay in hospital. The care homes have embraced this service working closely with all concerned to ensure that the agreed outcomes are met.
Initially getting appropriate referrals was difficult as after assessment, we found we were able support the majority of service users/patients within their own home. At present we are working with the local GPS and Geriatricians to build up trust and confidence in this service so they will refer more complex cases that require the twenty four hour support from the team within the care home.
What you did?
The change fund has facilitated joint working with the Private Providers and Health and Social services resulting in an enhanced service for the service user/ patient. Training on enablement was disseminated to our partners in the care homes in the form of a work book and facilitated by IC&ES physio /Occupational therapist. Communication between all partners is crucial in order that we meet the outcomes for the Service users /patient.
Mrs G was found out in her garden area hiding in a confused state by the community alarm staff, GP admitted Mrs G to hospital through the emergency department. Mrs G had acute confusion; she was treated for a chest /urine infection by anti biotic therapy which resolved the delirium. After a short stay in Crosshouse hospital Mrs G with agreement from family was transferred to the step down bed at the care home for a short period of rehabilitation. Mrs G was clear that she wanted the opportunity to be supported at home. The plan of care and out comes were agreed with all parties involved in Mrs G’s care. The care home staff, Mrs G and IC&ES worked together to achieve Mrs G’s outcomes within the safe environment of the care home. Mrs G remained in the care home for 7 days, with daily intervention from IC&ES Mrs G’s confidence and mobility improved enough for her to return home with an appropriate care package.
What were the outcomes - benefits or otherwise?
The outcome for Mrs G was that she was able to return to her own home safely and to prevent an admission to long term care at that time. Mrs G remained at home with an enhanced package of care until she made the decision that she was unable to remain at home and a care home would be able to meet her needs more effectively