Intermediate Care – Fife

Examples of Practice

The aim of establishing ICASS in Fife was to transform community services by bringing together uni-disciplinary teams to utilise fully resources available in line with demand, and to coordinate care through a single point of access (SPOA). It contributes to our commitment to ensure the closer integration of the range of community services under one system.

It aims to improve quality of care and outcomes for older people whilst allowing them to remain independent within their own homes or communities, provides alternatives to hospital admission, reduces the number requiring long term institutional care, reduces length of stay for those who require a hospital admission.  It aims to address the following:

  • Moving from an inpatient model of care to a robust community based model of care involving older people and their carers and families in care planning
  • Bringing together teams to make more efficient use of resources to meet the needs/demands of the increasingly elderly population
  • To provide a single point of access
  • To provide alternatives to hospital admission
  • To reduce length of stay if an admission is necessary
  • To provide assessment and care in the person’s own home or a homely setting
  • To achieve and sustain maximum potential and independence; and
  • To reduce numbers going into long term institutional care.

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Hospital at Home

Examples of Practice

The challenges included shifting from institutional based care to care at home or a homely setting, the need for quicker assessment and care plan coordination and formulation in a more homely setting taking into account the person’s conditions and home situation instead of needs and support being assessed in a ward setting.

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New Horizons

Examples of Practice

The issues addressed are: build social networks and opportunities for participation; suitable and varied housing and housing support; timely adaptations including housing adaptations; co-production; and reablement & rehabilitation. The New Horizons project for older people aims to reduce isolation, improve mental health and wellbeing, and maintain independence within the home

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Intermediate/Reablement Care Beds

Examples of Practice

The facility was established to pilot a model that would:

  • prevent unnecessary permanent admission to residential care
  • prevent unnecessary admission to hospital.
  • facilitate discharge from hospital and contribute to managing delays in discharge from acute or community hospitals.
  • deliver support to ensure a safe and full re-integration into the Service Users home and local community.
  • assist Service Users’ in setting and achieving their planned goals, placing the emphasis on the Service Users needs. Goals will be set with the service users and reviewed weekly or as required throughout their stay
  • support Service Users to regain and maintain daily living skills.
  • support carers in their role during a person’s stay in the unit and after the assessment period is complete.
  • respond quickly and flexibly to the changing needs of the Service Users to support their return home.

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