1. Key Contacts Argyll and Bute Liz Higgins Lead Nurse elizabeth.higgins@nhs.net Fife Yvonne McCallion, Lead Manager Reshaping Care yvonne.mccallion@nhs.net Glasgow City Stephen Fitzpatrick Head of Older People Services StephenNBH.Fitzpatrick@glasgow.gcsx.go v.uk North & South Lanarkshire Dr Graham Ellis, Assoc. Medical Director graham.ellis@lanarkshire.scot.nhs.uk Borders Laura Jones Head of Quality and Clinical Governance Laura.Jones@borders.scot.nhs.uk Thanks to everyone involved in the planning and delivery, and everyone who attended for making it a successful day Enabling best care for older people living with frailty Update 1 June 2015 Dates for your diary Working in Partnership Web ex series Know where to turn- July Knowing what to count and counting what matters – Aug 24Aug Workshop HOLD THE DATE Workforce capacity & capability 3 rd sector contribution- Sep October 26-27 th HOLD THE DATE 2 day Older people learning event Heriot Watt, Edinburgh. Buddy up On 1st June 2015 we met with key stakeholders from Health & Social care partnerships and 3 rd sector colleagues (Argyll and Bute, Fife, Glasgow City, North and South Lanarkshire & Borders) to launch our improvement programme enabling best care for older people living with frailty. The day created an opportunity to share, and learn about, the fantastic work taking place to support older people living with frailty. We also asked for volunteers to buddy up and share their knowledge and expertise with others in the programme. We had a few volunteers on the day but would really like more. PHYSICAL ACTIVITY Melanie.menzies@nlleisure.com Health & Wellbeing Manager INTEGRATED DISCHARGE HUB Antoni.Anderson@southlanarkshiregcsx.g ov.uk HEALTHCARE ECONOMICS – Healthcare Improvement Scotland brian.o’toole@nhs.net ANTICIPATORY CARE PLANNING Jean.Donaldson@lanarkshire.scot.nhs.uk lorna.dunipace@ggc.scot.nhs.uk HOSPITAL AT HOME claire.ritchie@lanarkshire.scot.nhs.uk If you would like to be a buddy, please let us know and we will circulate your details Welcome to Thomas Monaghan. Our new Improvement Advisor for the programme. Email: thomas.monaghan@nhs.netthomas.monaghan@nhs.net

2. Partnership Pledges 1.Review data and evidence to understand current state and identify priorities 2.Look at readmissions in Campbeltown (triggers for further scrutiny engage with local GP for CGA) 3.Connect with Pete - SPARRA 1.Identifying frailty in the community/at home SPARRA Rockwood frailty index ISD Guidance for GPs – pathways and models. 2.ACP 3.Optimise use of STAR beds 1.Work with SAS to reduce the number of patients conveyed to hospital. 2.Single point of access - work with SAS, ERC, NHS24. Understand what they need from the Board. 3.Is there capacity for the increased traffic? Argyll & Bute Fife Lanarkshire 1.Intermediate care beds – case note audit (Apr-Jun) readmission within 1 week. 2.GP frailty screening (Mid Jun – end Jul) ‘Is there anything you cant do now that you could do 6mths ago?’ Evidence review. 3.Review 20% patients returning home from intermediate care. What services are they using at home? Patient outcomes? Glasgow Borders 1.Frailty screening tool in ED department & minor injuries/day hospital 2.Ask project team to propose areas for spread 3.Revise and strengthen membership of project team and programme board Meet with Scottish Ambulance Service about single point of access We would like to offer each partnership an opportunity to undertake a deep dive into your data as part of your diagnostic work and Thomas Monaghan will be in touch to arrange a time to speak to you About how we might help In the pipeline