@jitscotland JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Dr Anne Hendry National Clinical lead for Integrated Care Falls and Unscheduled Care

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors SAS activity for >65s Dec 09 – Nov 10 Number of Incidents for top 5 codes Sick person 37,487 Falls 34,509 Breathing problems 24,528 Chest Pain 17,253 Abdominal Pain 10,683

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Falls related activity and costs 1 in 5 over 65s presenting to SAS have had a fall Three quarters of older people who fall are aged 75+ Each day SAS attends over 100 over 65s who fall Most are conveyed to hospital at cost of around £11m Costs of falls to health and social care services in Scotland are estimated to exceed £471m per year Each Hip fracture is estimated to cost around £39,500 Personal costs !

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Significant variation across Scotland. 4

Reshaping Care Pathway

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Active and Healthy Ageing 7

Range of technologies…

Technology Enabled Integrated Care

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Intermediate Care 11

FALLS EMERGENCY PATHWAY (EDINBURGH) The person has a fall at home Calls 999 and requests assistance Assessment and treatment by ambulance service. Risk assessment carried out using Protocol for Falls Assessment Ambulance service responds Referral for either: Rapid Response (urgent assessment) same or next day or Falls Assessment within 7 working days In hours: Mon-Thurs pm Fri Call Out of Hours: FAX COPY OF PROTOCOL FOR FALLS ASSESSMENT TO Rapid Response Team responds Multifactorial falls assessment and intervention aimed at reducing risk factors Provision of telecare equipment to support safety at home Referral on for further assessment as appropriate Version Patient requires urgent or non-urgent falls assessment at home No further action Conveyed to hospital If uninjured refer to Fallen Uninjured Person Pathway

Procedure for Ambulance Service informing Perth and Kinross Falls Services about patients over 65 years who have experienced a fall Older Person Falls Ambulance Service responds to 999 call One-point entry system with Gate-keeping/screening of referrals by Falls Clinic staff and allocation to specialised falls clinics Carolyn Wilson, Falls Service Manager Patient requires hospital admission A+E admission Patient refuses hospital admission Patients (over 65) who have fallen and do not require admission to hospital for any reason Patient asked if information can be shared with Perth and Kinross Falls Service Ambulance crew fax P&K Falls Service Referral form to Rhona Blackburn on as soon as possible after incident. Ambulance crew complete Perth & Kinross Falls Service Referral form Consent declined Falls prevention information booklet issued Paul Kelly Patient allocated to appropriate falls clinic Aberfeldy Blairgowrie Crieff Auchterarder Perth

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Community Alarm Service (CAS) Perth and Kinross 15 Falls screener post was funded by the partnership to offer multifactorial risk screen and intervention to new CAS clients who have fallen two or more times in 6 months (or at staff discretion) Falls checklist used by CAS staff to describe the circumstances of the fall and to upload the profile to the electronic system (Swift) Falls screener also provides MFS for care at home clients and sheltered housing residents who have fallen. Partners involved include P &K Council Community Alarms Service, Perth and Kinross Falls Clinic, Community Rehabilitation Team, Social Work OTs, GPs and others.

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 16

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Highland Falls/Frailty Pathway (Inverness Wick and Caithness Districts) 17 Following their ‘primary survey’ the SAS contact the ‘Highland Hub’ to directly access further care and support for an uninjured person. If SAS crew has immediate concerns for the person’s welfare, the Hub can access urgent responder attendance via the British Red Cross. At the same time a referral is ed o the community AHP team and community care team requesting follow-up the next working day or non urgently by the community AHP team and the community care team. Over a four month period conveyance to hospital in the Inverness District reduced to 51% from 85% (70 referrals).

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Frailty is a dynamic functional state 20 Potential Reversibility

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Everyone Matters working seamlessly with colleagues in NHSScotland and partners who provide care making more and better use of technology and facilities to increase access to services strengthening workforce planning to ensure the right people, in the right numbers, are in the right place, at the right time putting new and extended roles into practice

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors Food for Thought 23 What can you and your team / service contribute to reducing falls? How can your work help to improve the experience and outcomes from a fall ? Who can you work with to improve the emergency response for people who fall or are at risk of falling ? Think Frailty Prevent Falls