The following Atlas provides information on the provision of Intermediate Care & Reablement across Health and Social Care Partnerships in Scotland.
Some members of the Living Well in Communities and Midlock teams at the NHSScotland event
The Living Well in Communities team is working with Health and Social Care Partnerships in Glasgow City, West Dunbartonshire and Midlothian to test the electronic frailty index (eFI) to identify people over 65 who are living with frailty in the community. The Living Well in Communities team have developed an assets-based approach to support evidence-based interventions that are tailored to the individual. This article looks at the work to date with Midlock GP practice in Glasgow.
The testing in Midlock GP practice
The eFI uses GP read codes to calculate an individual’s degree of frailty and stratifies them into fit, mildly frail, moderately frail and severely frail. The tool has been validated in England. The purpose of testing at Midlock GP practice was to determine if the tool was accurate in a Scottish context. We have been working with a GP and other members of Glasgow City HSCP, including housing and the voluntary sector. The testing involved stratification of the GP population for frailty and reviewing case scenarios to determine if the eFI tool fits with a Scottish population.
Following this process, there was broad consensus at Midlock GP practice that the eFI categories were accurate for their population. This prompted them to consider, how do we support people who are living with frailty? What does this mean for the individual? and how can we work collaboratively in the community to support them?
The case scenarios identified anticipatory care, crisis prevention and palliative and end of life care work as areas where the team could make a difference to support people to remain in their own home.
The team identified three stages of frailty to focus on initially:
- people who are changing from mild to moderate frailty (anticipatory care),
- people who are moderately frail with the biggest change in eFI score (crisis prevention), and
- people who are severely frail with the biggest change in eFI score (palliative and end of life care).
Midlock GP practice has developed a virtual way of working within the multidisciplinary team and have used the Living Well in Communities falls and frailty intervention tool to guide the development of a falls and frailty collaborative working in the community. The team have found the tool beneficial to use during frailty case reviews, as it promotes holistic assessment across agencies and is a useful prompt that helps staff by signposting to partner agencies that could assist in care provision. Incorporating the tool in the case reviews highlighted five key interventions which should be implemented for every individual identified as frail (#Frailty5):
- Frailty identification and coding on the GP system
- Anticipatory Care Plans uploaded to eKIS
- Key worker
- Carer support and assessment
- Falls & Frailty Conversation
These interventions had previously not been happening for every person, every time.
The impact so far
“The frailty tool is excellent guidance to follow and know where to signpost people.”
“There was a richness of information shared by the MDT and it’s amazing to know how many supports are there for people.”
All of the team at Midlock have made commitments to support the work. Community nurses are engaging more in anticipatory care planning conversations, and the third sector feel that they are an integral part of the work, and that their contribution is valued. The inclusion of housing options in the tool is valued by the team, and the tool has made them aware of all the supports that are available.
Supporting the Midlock team to test the efi and the falls and frailty interventions tool has helped the team to change the way that they work, with benefits for both staff and those who receive care.
Find out more about the Living Well in Communities frailty and falls work on the ihub website.
We also displayed a poster on our work at the NHSScotland event in June, which you can view here.
On 27th June we held our latest national learning event on the neighbourhood care work being tested across the country.
With representation from Health and Social Care Partnerships and national organisations, the aim of the workshop was as much about exploring the challenges to developing this model of care as it was about sharing learning and increasing knowledge across Scotland.
After welcomes and introductions from Ruth Glassborow (Director of Improvement Support and ihub), Chris Bruce provided some background on how Scotland became involved in learning from the Buurtzorg model in the Netherlands, with an overview of the work so far.
All agencies and partners involved in developing local models – using the principles of Buurtzorg (and in the spirit of self-organisation) – have worked together to develop tests and start building a national learning community.
The testing principles in Scotland
- Promote independence
- Continuity of support and carer – reduce fragmentation
- Self-organising, flexible teams, focused on people
- Back office / organisation focused on staff and people
- Opportunities – accelerate integration at point of care, empower nursing and social care workforce, change commissioning practice
Each of the eight neighbourhood care test sites (Borders, Dumfries & Galloway, Highland, Stirling and Clackmannanshire, Angus, Aberdeen City, Western Isles and Cornerstone) gave an update on what they hoped to achieve from the model, what their progress has been and what challenges they’ve faced so far.
There were a number of common themes across the test sites when discussing developments: governance, communication, engagement, change management and recruitment.
There was a feeling that some aspects of clinical and corporate governance were making testing more difficult than it needed to be. Should we take a risk proportionate approach, rather than risk averse? Do we have to be (more) brave?
Isn’t this the realistic approach to medicine?
The sites highlighted a need for regulations to be simple, straightforward, scaled-down, and to learn from the 3rd sector. Cornerstone rewrote and reduced their policies and procedures from more than a hundred to single digits.
The Cornerstone approach:
Start with nothing, then see what you actually need.
There was agreement that for a lot of people working in the service there is strength to be drawn from the common goals of the neighbourhood care models.
It’s a way of working that empowers staff, promotes autonomy and self-management. It’s a model that can offer increased satisfaction for those working in it, leading to better recruitment, retention and less absence.
The importance of buy-in from all staff (including those in corporate and leadership roles) is hugely important to progress.
We are trying to introduce change in a complex environment. And for some this will lead to uncertainty, around themselves, their role, their workplace. Sharing success from the testing can help reassure people that this can work in Scotland.
Part of this will come from our internal and external communications, information sharing and engagement.
We will continue to develop the self-managing network for learning and sharing best practice across the test sites, as well as building a digital platform for updates and charting progress.
We’ll have key messages that can be use locally and nationally to help spread the word.
What ties all of this together is building trust between all the different agencies and people involved in health and social care.
Let’s talk about how we should co-operate together instead of competing; with other professionals, with informal carers and other organisations. How we make younger people enthusiastic for the profession and much more.
Jos de Blok, Buurtzorg founder
We want people to see the successes from the test sites and for them to want to be a part of it.
We want to share people’s stories, share learning and promote success more widely.
So check back over the coming months when we’ll update you more regularly on the work of the individual test sites, hopefully looking at the practical aspects of the models as well as the broader themes and issues.
Find out more about Anticipatory Care Planning at myacp.scot
by Laura Dobie, Knowledge and Information Skills Specialist
On Friday 12th May I headed to Inveraray for the Argyll and Bute Nursing Excellence Awards. This is the first year of the awards, which celebrate outstanding care by nurses and other healthcare professionals, and were organised to coincide with International Nurses’ Day. Staff were nominated by colleagues, and there was also a patients’ choice award. Nominations were based on caring behaviours, including attentive listening, honesty, patience, sensitivity and respect. Continue reading “Celebrating great care at the Argyll and Bute Nursing Excellence Awards”
I am absolutely delighted to have taken on the role of National Clinical Lead for Palliative and End of Life Care for Nursing.
Having been in post for a few weeks I’m now beginning to link in with key individuals in each of the Health Boards to truly represent nursing across Scotland, ensuring the nursing voice is fully heard on behalf of patients and those important to them.
My passion is communication and I believe fully in the human connection that we as nurses have with our patients.
Compassion is about the human experience of noticing, feeling and responding.
Delivering compassionate care has to be fundamental for all staff, and supporting nurses to be able to do this is one of my main goals.
Strategic Framework for Action
The Scottish Government is committed to working in partnership to support a range of improvements in the delivery of palliative and end of life care in Scotland. Continue reading “Introducing Sandra Campbell”
Our intermediate care and reablement event took place at 200 St Vincent Street on 21st March 2017 and shared findings from our intermediate care scoping work, and learning from services across Scotland. The event was supported by the Scottish Government, Social Work Scotland and the Health and Social Care Benchmarking Network.
Isla Bisset from the Scottish Government presented data on delayed discharges from January 2017, and Deanna Campbell gave an overview of the intermediate care minimum dataset, which records different interventions, their impact, and whether an anticipatory care plan was in place. Outcomes included avoided hospital admissions and early supported discharge. Continue reading “Discussions from our intermediate care and reablement event”
Around 54,000 people die each year in Scotland, most following an illness. Four times as many are affected by the loss of a loved one.
How do we best support these people to live well, help manage conditions and give quality and meaning to their life as their health declines?
This is the question I ask myself, as the Improvement Advisor for Palliative Care within Living Well in Communities, and as a daughter who looked after her Mom during the last few months of her life.
I loved my Mom so very dearly, and I started grieving while still caring for her. It was a time I found incredibly difficult.
Mom wanted to stay home but the say of doctors and the power of the system dominated the decision-making around her care. It seemed to me you were either in the system (hospital) or out (on our own).
Her palliative journey was one of pain and crisis. As her main carer, I gradually became exhausted and, whilst we tried to treasure her final months, her last few days were chaotic and full of interventions rather than the peace and respect she so very much deserved.
Many things have changed since then. Continue reading “Introducing Michelle Church”
by Laura Dobie, Knowledge and Information Skills Specialist
A person with frailty can experience serious adverse outcomes following even a relatively minor illness. Timely identification of frailty can help to reduce the likelihood of a poor outcome following an intervention (or eliminate the need for an intervention entirely) and support the long-term management of people’s health needs.
If we can identify people with frailty in the community, we can offer preventative support that could improve their quality of life and reduce the risk of unscheduled admissions.
There are a number of tools which professionals can use to screen people for frailty (see the British Geriatric Society’s Fit for Frailty guidance). However, many of these tools are based on questionnaires that require practitioners to have direct contact with individuals and can only be used to assess people who are actively engaged with services. It would be resource-intensive and challenging for services to screen large population groups for frailty using these individual assessments.
The risk stratification tool, Scottish Patients at Risk of Re-admissions or Admissions (SPARRA) identifies individuals within the whole population at risk of hospital admission based on nationally-collected data on acute admissions and community prescribing. However, it does not discriminate frailty from other high-risk population groups and can only identify individuals who are known to services, as they have had recent acute admissions or have been prescribed high-risk medications. Alternative population screening tools are needed to identify people with frailty living in the community. Continue reading “Using a population screening tool to identify people with frailty in the community: the e-frailty index”