Managing Frailty The Fife Way: Summary and Resources


Managing Frailty the Fife Way took place on 17th March 2016 at the Carnegie Conference Centre. The event was an interesting and informative day which explored good practice in managing frailty from Fife, highlighting innovative ways of working and successful examples of integration. There was a lot of sharing and learning on Twitter throughout the day, and you can view a selection of tweets from the day on the event Storify. You can also view the agenda for the day.

Dr Graham Ellis, National Clinical Lead for Older People and Frailty, gave a lively introduction to the day and declared an ambition for Scotland to be the best place to grow old.

Professor Scott McLean, Chief Operating Officer (Acute Services) NHS Fife, gave an overview of acute care redesign in Fife. He argued that it is a myth that hospitals are places of safety and explained their decision not to open surge wards, commenting that they are not good for older people or staff.

Dr Seònaid McCallum discussed health and social redesign in Fife. She emphasised the importance of relationships and building bridges, and the continuous nature of the work.

Karen Goudie, Joy Reid and Louise Kellichan presented on Frailty at the Front Door, highlighting NHS Fife’s frailty screening tool, their frailty huddles and the Integrated Assessment Team’s journey to a 7-day service at the front door.

Avenue Care’s Francis Davidson discussed their work on the Short Term Supported Discharge project, which aimed to help people to recover in their own homes, eliminating the need for a stay in hospital or readmission to hospital. She highlighted the success of joint working on the project and argued that the project has demonstrated that integration really works.

Susan Millar described person-centred discharge, and Jill Dow and Lorna Mackenzie highlighted the benefits of intermediate care and new models of care.

Pam Livingstone and Gwyneth Thom gave an overview of Fife’s Hospital at Home service and its benefits, including care that is tailored to the individual and a shorter length of stay.

Allison Nellies discussed Discharge to Assess, a recent test of change in NHS Fife which has been most widely implemented in Sheffield. Its context-specific approach to assessment leads to a safer discharge for patients, preventing unnecessary readmission.

The afternoon breakout sessions gave delegates the opportunity to explore the work that was covered in the morning presentations in more depth. Breakout Session 1 looked at frailty at the front door and the new frailty advanced nurse practitioner and assistant frailty practitioner roles.

Breakout Session 2 looked at how to support discharge from the acute hospital, further exploring the work of Avenue Care Services.

Breakout Session 3 allowed delegates the opportunity to ask questions about the following examples of meaningful alternatives to admission from Fife: intermediate care housing, short term assessment and re-ablement, voluntary agencies and hospital at home.

Breakout Session 4 explored the improvement work of the NHS Fife Older People’s Collaborative.

Professor Brendan McCormack, Head of Division of Nursing / Head of QMU Graduate School, gave a very interesting and thought-provoking presentation on frailty and resilience. He stressed the need for more early intervention work in frailty and argued that interdisciplinary working should be the norm. He highlighted the benefits of community groups and the need to incorporate them into care pathways, and argued that what can seem insignificant to practitioners can be very important to older people and their families.

A lively discussion panel allowed delegates to further explore the topics which were covered over the course of the day, and Scott McLean rounded off a very successful day of sharing and learning.

Overall, this was an inspiring event which allowed health and social care workers from Fife to share good practice from the health and social care partnership in managing frailty and caring for older people.


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