1. RESHAPING CARE FOR OLDER PEOPLE
Val Hatch NHS Fife, Martin Thom Social Work and Kenny Murphy Fife Voluntary Action

2. INTERMEDIATE CARE & SUPPORT SERVICES
COMPONENT PARTS
Hospital at Home
Intermediate Care
Home Care
Intermediate Care Framework in Fife also includes
Independent Sector Beds
Alan McLure / Valley House
Single Point of Access for hospital discharge being developed thought the discharge hub at Victoria Hospital
Intermediate Care
Hospital at Home
Patient/Service User
INTRODUCTION
INTERMEDIATE CARE & SUPPORT SERVICES

3. HOSPITAL @ HOME Community Life Assessment & Clinical Care Patient
Activity
Net Budget £2.205M
A community clinical assessment and care model that support people at home as an alternative to hospital admission
Provision
Implementation Plan
DWF April 2012
KLM July 2013
GNEF Sept/Oct 2013
Total New Patients
Ave LoS 5-8 days
Age Criteria Adults
Suitable Conditions
Infection, eg. Chest, urine, cellulites
Delirium
Falls – no lower limb fracture
Exacerbation of Chronic Disease
Reduced mobility related to illness/accident
Dehydration
Feedback from users
Positive and nearly always about being cared for at home.
Investment from Change Fund £2.205M
Community Life
Assessment
& Clinical Care
Patient
HOME

4. INTERMEDIATE CARE TEAMS
Activity
A multi-disciplinary team of practitioners who prodie a period of rehabilitation ina persons home.
Focussed on both prevention of admission and early supported discharge from hospital.
Co-located in three areas in Fife:
QMH
Whyteman’s Brae
Adamson
Provision
Approximately new referrals each month
Ave Los 21 days
Age Criteria over 65’s
Feedback from users
No structured process to measure, however evaluation indicated a high level of satisfaction
New funding provided through LUCAC £500,000
Community
Care At Home
Patient/Service User
INTERMEDIATE CARE TEAMS

5. DISCHARGE HUB What we have done
2 Social Work Service Reablement Occupational Therapists, 6 NHS Fife Patient Flow Co-Cordinators and 1 Administrative Support
Purpose
To maintain patient flow from hospital focussing on support for discharge for frail complex patients focussing on return home.
To provide quicker access to;
Community rehabilitation services
Homecare services
Downstream and/or intermediate care bed options
Reduce delays
Provision
Support across all hospitals in Fife
Fully implemented in VHK by end December 2013
Activity
In 4/5 wards approx 40 individuals per week a large number of which are going directly home.
Investment
LUCAC / NHS Fife £321,550
Social Work Service £84, 000
*(Area Team Link Social Workers Up to £237, 500)
DISCHARGE HUB

6. HOME CARE System Community Service User
Activity Net Budget £18M Current overspend of £3.156M
Service User Developing a model to support people to live at home, as independently as possible through adopting and delivering a reablement approach across all Care at Home provision.
3000+ individual packages
1.2M hours of care at home
Telecare clients 12/13 = 1,287
Community alarms 12/13 = 6,974
Community Benefits
Supports safe maintenance of individuals
at home and within the community for as
long as possible and promotes
independence and community
integration.
System
Increased number of Home Carers,
Home Care Managers, Specialist
Reablement Occupational therapists and
Home Care Reablement Training Staff all
employed through Change Fund
Investment of £2M.
Telecare investment of £350,000.
System
Community
Service User
HOME CARE
Customer Satisfaction
Home care (November 2012) 91% satisfied
Telecare (February 2013) 93% satisfied
Community Alarms (February 2013) 96% satisfied

7. INTERMEDIATE CARE BEDS
What have we done
2 local Authority Homes (14 beds)
3 Independent Sector Homes (20 beds)
Service User Benefits
Access to a safe and enabling environment where the focus is on improving well-being, confidence, resilience and skills improvement. That aims to return individuals to live safely within their own homes.
Community Benefits
Reduces unnecessary long term care placements and admission to hospital.
Assists to facilitate discharge from hospital.
Supports a safer re-integration home and into the community
System Benefits
Opportunity to provide intensive reablement within a supportive environment to build skills and resilience and allow individuals to return to live within their own homes.
Allows detailed holistic assessment of skills etc. to ensure that no-one is admitted into long term care unless that is the most appropriate resource to meet their needs.
Investment
Change Fund £400,000 for independent sector
home provision.
Fife Council investment in local authority care home
provision £254,436 for both Valley House and Alan
McLure.*
INTERMEDIATE CARE BEDS

8. RESHAPING CARE Investment: £70.542m
Older Peoples Social Work services provide support people to live as independently as possible within their own communities. The service has over 1590 staff members, and in addition to assessment, care management and the protection of older people at risk of harm across Fife, we provide a wide range of in-house and external services, mostly aimed at protecting individuals who are most at risk in the community. The services provided include Long Term Care placements and funding, Day and Respite care facilities, care at home services, and a number of services to prevent admission into long term care, and hospitals.
The change fund is being used to change a number of these models and services, and by working in partnership we hope to continue to develop sound models that will shift the balance of care and reshape services for older people across Fife.
RESHAPING CARE

9. LIFE LONG LIVING 11 Projects
Not just “capacity building” but making real contributions to
Preventative & Anticipatory Care
Proactive Care & Support at Home
Effective Care at Time of Transition
Hospital & Care Homes
Change Fund Investment £500,00