Delivering Better Outcomes – Helping Older People to Help Themselves Tony Homer – Associate, Joint Improvement Team

Outcomes approach to community care

Outcomes Framework Community care users feeling safe Users and carers satisfied with their involvement in the design of care package Users satisfied with opportunities for social interaction User assessments completed to national standard Carers assessments completed to national standard Care plans reviewed within agreed timescale Shift in balance of care from institutional to ‘home based’ care People 65+ with intensive needs receiving care at home People 65+ receiving personal care at home Emergency bed days in acute specialties for people 65+ People 65+ admitted as an emergency twice or more to acute specialties People 65+ admitted twice or more as an emergency who have not had an assessment Patients waiting in short stay settings, or for more than 6 weeks elsewhere for discharge to appropriate setting People waiting longer than target for assessment People waiting longer than target time for service carers who feel supported and capable to continue in their role as carer Access Carers Experience Balance of Care Risk of Admission Quality Assessment Outcomes Framework

Outcomes approach to community care

Talking Points – core concepts Understand outcomes as the impact or end result of service(s) on a person’s life The user or carer is involved in identifying desired outcomes = setting goals in partnership with services Partnership is key – users, carers, services, other community resources – to delivering outcomes

Service user defined outcomes Quality of lifeProcessChange Feeling safe Having things to do Seeing people As well as can be Life as want (including where you live) Listened to Having a say Respect Responded to Reliability Improved confidence Improved skills Improved mobility Reduced symptoms

Carer defined outcomes Quality of life for cared for person Quality of life of carer Coping with caring Process Quality of life for cared for person Health and wellbeing A life of their own Positive relationship with person cared for Freedom from financial hardship Choices in caring including limits Feeling informed/skilled/ equipped Satisfaction in caring Partnership with services Valued/respected Having a say in services Responsive to changing needs Meaningful relationship with practitioners Accessible and available and free at the point of need

Grappling with the Service Change Agenda

Cross-cutting policy priorities >Personalisation >Self Directed Support >Telehealthcare >Safety >Information systems >Service integration

Service Clusters >Communities and informal networks >Long term conditions >Crisis care and interim support >Housing and care options

Communities and informal care >Supporting informal carers and volunteer networks >Community capacity building By: >Better understanding the size, profile and needs of the informal carer population >Taking a non specialist perspective on what resources look like – not overlooking universal public services >Involving all sections of the community so that they feel included and recognising that they have a contribution to make >Investing in the potential of the current community

Communities and informal care – South Ayrshire >Community development approach adopted across regeneration, health and children’s services. Now also incorporating Older People’s services >Model based upon Asset Based Communities approach >Focussing upon Girvan, a small costal town/hinterland with regeneration funding and a new community hospital >Care home re-provisioning with ECH being planned >GIRFEC strategy included in developing agenda for change – recognising everyone’s place in the community

Long Term Conditions >Long term care collaborative >Supporting better self care >Shifting investment upstream into anticipatory and preventative care >Telehealthcare >Using a re-ablement approach to re-skill and re-motivate users rather then create dependency

A Planned Approach to Patients at High Risk of Re-admission to Hospital – Ayrshire & Arran >Use of SPARRA data to predict highest risk patients >Quarterly review of highest risk patients >Encourage use of self-management plans – GPs and DNTs >Review of all emergency admissions – A&E and Acute >Notification to NHS 24 and ADOC >Consideration of pulmonary rehabilitation

Crisis care and interim support >Avoiding unplanned hospital admissions and readmissions >Avoiding delayed hospital discharges By: >Appropriate rapid response >24/7 cover >Intermediate care in a variety of settings >Telehealthcare >Respite support for carers

Crisis Care – Community based intermediate care service - Orkney

Accommodation and care options >Demographic impacts and housing >Housing quality and accessibility >Owner occupation and the social rented sector >Care Homes Aspects of the way forward: >Investment in normal housing >Practical services to support householders >The challenge of cross-tenure initiatives >Specialist housing >New roles for care homes

Accommodation and care options – Scottish Borders >Small rural town with dispersed hinterland population >Long term care home for people with degenerative conditions >Move to tenanted flats with onsite care and support in community >Re-ablement and re-skilling approach – reduced dependency >Social, activity and community engagement support >Shift involved access to state benefits – managing their own money >Gradual introduction of ILF applications/funding and shift of purchasing control to users >Adjustments to core provider budget and use of PAs

Things to remember What would help us to help ourselves? >Easy access to good information >Choice - real options that address your own circumstances >Control over deciding upon your preferred package / pathway >Self managed or actively involved in service planning/delivery decisions >Able to decide what opportunities and potential risks are okay for you >Within a supportive process that is driven by what works for you