Falls Pathway

Examples of Practice

Previous mapping of the falls pathway had demonstrated that there was no clear systematic approach to the identification and onward referral of those presenting to the A&E department at the local hospital with a fall.

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Access to Comprehensive Geriatric Assessment in the Community

Examples of Practice

Anticipating patients that are moving towards a health transition because of emerging health issues.

In Moray we monitor daily the number of patients that are over 65yrs, who attend A&E and are subsequently discharged. We used the Change Fund to second a senior nurse practitioner to work alongside a Consultant Geriatrician to follow up the patients who were discharged. Case studies suggest that early intervention of this type has prevented further deterioration or enabled planned interventions removing the unpredictability of an unscheduled admission.

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Joint Equipment Store

Examples of Practice

Investment to make improvements in the community equipment store to ensure systems are in place to provide outcome focused assessment and the provision of an effective equipment service – This is recognised as the responsibility of all care groups and services as a means of complementing other service provision, interventions and supporting overall service delivery e.g. facilitating hospital discharge.  The Joint Equipment Store was working at full capacity to accommodate the increasing numbers of equipment requests and increasing costs as we strived to support more people in their own homes.

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Nairn Anticipatory Care Planning (ACP) and Integration: A Primary Care Pilot Study Aimed At Reducing Unplanned Hospitalisation

Examples of Practice

The number of people in the UK aged over 65 is growing and is forecast to reach 16.1 million by 2035.  The burden of disease associated with aging will increase as will the demands on health services including end-of-life and palliative care.  The National Confidential Enquiry into Patient Outcome and Death in 2008 found that rather than advanced care planning and palliation taking place, some patients were subjected to excessively active interventions in their last months of life.

The pilot study aimed to ascertain whether using primary and secondary care data to identify patients at risk of hospital admission and agreeing and implementing an Anticipatory Care Plan in this population could help to reduce hospital admission rates.   Anticipatory care planning allows patients to express their wishes for care prior to a sudden deterioration in their health.

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