1. Jakki McLellan and Deena Jane Dean 2016

2. Hospital In hospital patients who are frail and at risk of falls are identified by ward staff via admission documentation and by Physio assessment. Daily Board Round attended by ward staff, Physio, OT A standardised balance score (Tinetti) is completed which follows the patient out into the community. The Reablement Team then monitor progress/highlight any deterioration. Rehab starts in the ward with Physio, Physio TI, and ward staff. OT intervention where appropriate.

3. In the community On D/C from hospital appropriate patients are referred to the Reablement Team by ward Physio. The Reablement Team consists of Physio, OT and Community Nurse. Most referrals come from ward and GP. Other areas that can refer into the team are; SAS, A+E, Community Nurses, care homes, Social Services, Consultants, Community Mental Health Team, Medical Imaging and MSK Physio.

4. Referral Process 3 1/2 years ago a single point of referral was developed for non-MSK Physio and the Reablement Team. Several meetings were held with the GP’s to gain information on what they felt would be beneficial and also education sessions were held as the Team developed. A clinical mailbox was set up to allow electronic referrals to increase efficiency in the process, reduce time between referral being made and received, allow improved data collection, reduce risk of loss of the referral, and to have better information to aid triage and lone working.

5. The mailbox can be accessed at any computer therefore allowing team members to access it at their different bases. A Physio database was also set up to allow closer monitoring of the waiting list with colour coding to highlight urgent patients and patients who have been waiting longer. The database allowed recording of multiple referrals and Physio intervention.

6. On D/C from Physio a D/C summary is inputted into the database and an D/C letter is generated and emailed directly to the GP. OT hold information on CareFirst system and email discharge summaries to GPs/referrers.

7. The Ambulance Service A simple referral form was developed with the ambulance team to capture patients who had fallen at home and who didn’t need admission. The referral would be left for the Reablement Team in the hospital and the referral triaged. The Team would contact the patient to make an appointment for an assessment. It was felt that doing this would allow us to capture patients who may otherwise be missed but who were at risk of further falls.

8. A+E Past 1 ½ years opportunistic screening questions have been used in A+E to capture patients who may be starting to have problems with balance/falls/frailty. The A+E card is photocopied by admin and left for the Reablement Team to triage and contact appropriate patients. The screening questions are also used in Physio, Community Nursing, OT.

9. Palliative Care No specific AHP Palliative care service Patients in the hospital and the community are seen when needed. Most input is around respiratory care and mobility in hospital and equipment needs at home.

10. Reablement Service Physiotherapy, Occupational Therapy, Community Nursing and close links with Social Services Reablement – where there is rehab potential or ability to sustain patient at home, input from one or more of the services Early discharge from hospital, prevention of admission to hospital, patients unable to attend out-patient clinic Weekly meeting to discuss current caseload, hold a database of Reablement referrals Referrals to team via clinical mailbox, picked up by most appropriate service(s) Trusted Assessor training – any member of the team can now provide basic equipment items

11. Reablement Referrals 232 referrals were made to Reablement between 1 st April 2015 to 31 st March 2016 Main referrers – GP (25%), Ward (19%), Community Nursing (9%), Social Services (8%) 34 were referred twice within this timeframe Current caseload 70 patients

12. Frailty Co-ordinated approach Weekly meeting between hospital, AHPs, DNs, social services, homecare, CPN, residential home, Dementia Support Worker Discuss new referrals e.g. for homecare, day care, permanent care Discuss admissions and discharges from hospital Discuss individuals causing concern

13. Falls Service Falls assessment – patient’s environment, risk factors, general health, balance, gait. Can be done by any member of the Reablement team. Falls classes – seated and intermediate classes led by Technical Instructor. 12 week programme aiming for self- management Interventions following fall – walking aid, equipment/adaptations, exercises, confidence building, highlight/minimise risks, education, mindfulness Consider reason for fall – often a sign of medical problem developing

14. Falls Screening Use every healthcare contact as an opportunity to screen for falls 4 screening questions (Level 1 from Prevention and Management of Falls in the Community) Direct referrals from Ambulance Service Service Users offered falls assessment in home or clinical environment Database of assessment results allows comparison of individual over time

15. Long Term Conditions Cardiac Rehab Programme – 12 weekly sessions Pulmonary Rehab – progressive programme, generally delivered in patient’s home (venues and transport are significant issues) Osteoporosis – education following diagnosis by DEXA scan Non-MSK – out-patient or domi as appropriate Chronic Conditions Mental Health – confidence building, anxiety management, symptom management, OT trained in delivery of Mindfulness interventions

16. Dementia Local Working Group established Getting To Know Me Document introduced. Liaising with SAS for transfer of document when patient admitted to hospital Development of dementia friendly designated hospital room/area Introduction of Pocket Ideas to hospital, care home and residential care. Workshops held for staff

17. Dementia (Cont) Dementia Support Worker employed Development of Dementia Friendly Communities – training to supermarket staff, transport issues Music in Mind Group established by local Minister Peace of Mind for help with Self Directed Support Packages www.peaceofmind.scotwww.peaceofmind.scot Umbrella Group – not exclusively for patients with dementia. Indoor crafts and gardening activities for socially isolated people

18. Service Developments Tai Chi for Rehabilitation Develop Mindfulness programme for falls prevention Continue with Mindfulness interventions to support self management of conditions Stronger links with home care team, develop training on Reablement, and systems to support integrated working Ongoing projects with Dementia Working Group

19. Case Study 1 80 yr old male, recent reports of falls, leg giving way, started using walking stick, no other health problems Wife, 20 yrs younger, resenting becoming carer Relationship and home environment becoming difficult Referred by social services to OT and Physio Assessment revealed Tinetti 22/28, significant reduction in activity/interests, lack of confidence, anxiety, muscle weakness Interventions – exercise programme, progressive walking practice, referral to falls exercise class, increased activity, provision of raised toilet seat, grab rails, chair height raised, community alarm Outcome – returned to driving, does shopping independently, walking outdoors independently, returned to community interests and activities

20. Case Study 2 June 2014 - 88 yr old male, lives alone, independent, initially referred for physio with reduced shoulder function, some memory loss noted August 2014 - Developed parkinsonian gait. Assessed by consultant, diagnosed with cerebral vascular disease, OT input for memory strategies & working with structure/routine December 2014 - Emergency respite arranged on mainland March 2015 – Fall, admitted to hospital. Diagnosed with Lewy Body Dementia. Referred to social services. October 2015 – frequent falls. Referred to Dementia Support Worker February 2016 – Bad fall at home, admitted. Unkempt, poor hygiene, agitated. Discharged with 4 care visits per day. Follow-up from multiple agencies. Difficulty settling at home, permanent care discussed with family. Eventually settled, accepting care at home June 2016 – fall, brought to A&E, seen by unfamiliar GP who was keen to admit him. No medical intervention required. Advised to get home as soon as possible. Referred for day care