1. Early Community Support for Frail Elderly: putting evidence into practice Dr Ellie Hothersall Consultant in Public Health Medicine NHS Tayside e.hothersall@nhs.net @e_hothersall

2. “All hands on deck” We need to find ways of ensuring a local focus on these issues. This should include access to good local data on public health issues, evidence of those interventions which are effective and access to expertise at the partnership level. This is a prime example of where significant local flexibility should go hand in hand with proactive efforts at a wider level to research and develop new approaches and promulgate them effectively. http://www.alliance-scotland.org.uk/download/library/lib_51f8dfb426a3b

3. The evidence says…

4. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/older-people-and-emergency-bed-use-aug-2012.pdf

5. Patient centred care improves outcomes Good or reasonable evidence of its potentially beneficial impact Good or some evidence for how to do it well

6. Community care is cheaper than hospital care http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/older-people-and-emergency-bed-use-aug-2012.pdf

7. Prevention is better than cure… “… flexibility in service delivery is a necessary condition for providing for people's needs at home. … this flexibility has been found to be difficult to achieve in the public sector because of the nature of existing employment contracts and the high costs of paying for care outside normal contract hours.” http://www.scotland.gov.uk/Resource/Doc/156782/0042157.pdf

10. Home visit request for elderly patient GP or other staff referral Hospital discharge team referral Daily “huddle” Assessment/ Comprehensive geriatric assessment ECS Coordinator MedicalNursingPhysioOTSocial work 3 rd sector Pharmacy

12. Practice Name Number of ECS cases* Practice population over 65 ECS cases per 100 eligible head of population Grove Health Centre11216126.9 Carnoustie Medical Centre7127352.6 Broughty Ferry Heath Centre6823023.0 Monifieth Health Centre6523192.8 Total31689683.5 * This equates to the number of referrals, i.e. a patient seen once, discharged and then re-referred in the course of the project would be counted twice.

14. Increase in Anticipatory Care planning (Monifieth and Carnoustie Health Centres) Data courtesy of Eric Blyth, Monifieth HC practise manager

15. Emergency admission numbers from practises involved in Winter project 2013-2014. Admission numbers Dec 2012- Feb10th 2013 Per 1000 practise population aged over 75 Dec 2013- Feb 9 th 2013 Per 1000 practise population aged over 75 % reduction Monifieth 9183635830.8% Carnoustie 8575726315.3% Broughty Ferry 8872736017.0% Grove 64778096increase Total 328288 12.2%

16. Mean length of stay for population aged over 75 years admitted from winter project practises. Winter project 2013-2014 Mean length of stayDec 2012- Feb 10th 2013 Dec 2013- Feb 9 th 2014 % reduction Monifieth7.56.217.3 % Carnoustie9.58.015.8% Grove18.111.834.8 % Broughty Ferry16.612.723.5% Total12.69.326.2%

17. Bed day impact of Enhanced support in the community. Winter project 2013-2014 Total bed days used Dec 2012- Feb 10 th 2013 Per 1000 practise population aged over 75 Dec 2013- Feb 9 th 2013 Per 1000 practise population aged over 75 % reduction Monifieth HC 69763739135743.9% Carnoustie HC 81171157750628.9% Grove HC 1160139878194132.7% Broughty Ferry HC 1463119993076236.4% Total 4131267935.1% Beds per night 53.634.818.9 beds per night (per 1000 practise population)

18. Reduction in Boarding from Ninewells Acute Geriatric Unit (Wards 5/6) 1253 bed days Data courtesy of Angie Miller, quality and effectiveness lead for planned care

19. Everyone [on the nursing side] tries to go to all the meetings [MDTs], to get extra information and learning. All nurses feel their skills and knowledge have been improved. When team members discuss going back to traditional District Nursing roles, they feel they will carry this skill and knowledge with them

20. Social work: I think that one of the reasons why the pilot has worked well is the link between the social care team and the nurses, and I think we should be doing more in order to replicate this across other areas.

21. Acknowledgements Dr Dougie Lowdon Dr Gail Young Liz Goss Sandy Berry Dr Alison Clement All the ECS team and GP practices