Examples of Practice

Community Connecting

Examples of Practice

The service aims to reduce social isolation and support individuals to establish/ re-establish sustainable connections with their communities. People coming to the service have often lost confidence after a fall, illness or bereavement.

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Advanced Nurse Practitioners – East Renfrewshire

Examples of Practice

Traditionally older adults with a long term condition who had or are having frequent uncomplicated exacerbations would be highly likely to be admitted to hospital care. This is due to the fact that other than GPs there is no other professional that has traditionally been able to offer advanced assessment in the community.

Under the new approach, the ANPs would identify individuals who would benefit from an anticipatory intervention and develop a personalised ACP through advanced nursing assessment to support them to be remain at home for as long as possible.

 

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Reshaping Care for Older People – The Lanarkshire Contribution Story Chapter 1

Examples of Practice

Stakeholders in North and South Lanarkshire Partnerships agreed a theory of change for Reshaping Care for Older People in April 2012, represented in logic model format.  The outcomes they want to achieve provided a framework for the evaluation.  The problem to be addressed was how to determine the success of a programme comprised of a wide-ranging set of initiatives. Some may be more successful than others, some may encounter unexpected blocks that thwart progress for a time, whilst others may simply turn out to be unworkable in practice. A means of bringing the different initiatives together under a common framework was required.

 

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Carer Aware Training

Examples of Practice

The aim of the Carer Aware training is to make the workforce:

  • More aware of Carers and their needs
  • To support the early identification of Carers and signpost them to relevant support.

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Intermediate Care – Step Up, Step Down

Examples of Practice

The issue we wanted to address was to expand the range of tiered interventions accessible to older people at key points of transition, recognising the limitations of the pre-existing service system. Gap analysis highlighted the need to create alternative inputs in circumstances where:

  • the older person has had a hospital admission and is clinically ready to leave hospital  but requires time to rebuild confidence and regain abilities in a reablement/enablement approach
  • the older person is at home and due to deterioration in health and wellbeing is at risk of avoidable admission to hospital, the newly developed intermediate care model being able to offer safe care with a lower tariff intervention
  • the older person is at home and due to deterioration in health and wellbeing or to a change in their social circumstances, [frequently this has taken the form of emergence of adult protection concerns] is at risk of crisis-driven avoidable admission to a mainstream permanent care home. The newly developed intermediate care model is able to offer assessment and a reablement approach which enables more effective care planning and decision making in a less pressured environment and context.
  • short term support is needed because the carer is unexpectedly temporarily unable to continue in the caring role
  • planned regular short breaks are required to provide stability, contributing to  prevention of unscheduled / crisis triggered transitions.

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