Primary Care – Living Well in Communities blog

The community-based interventions that can make a difference for people with frailty

Published on 13 July 20189 November 2018 by Living Well In CommunitiesLeave a comment

Cover image

We have recently published a resource that summarises the evidence for different community-based frailty interventions. This blog post gives an overview of the document and its features.

Why focus on frailty?

A person with frailty can experience serious adverse consequences following even a relatively minor illness. Its impact can be very significant in terms of consequent disability or admission to a nursing home.

If frailty is identified at an early stage and individuals are targeted with evidence-based interventions that can manage frailty, or reverse it, this can improve people’s quality of life and wellbeing. This reduces the likelihood that they will need to access unplanned services due to a crisis, which, in turn, reduces the use of expensive, unscheduled care.

The community-based interventions that can make a difference

The literature on frailty is vast. For the purposes of our resource we focused on interventions in frailty that are community-based, focused on the prevention of harms or poor outcomes, and supported by relatively high-level evidence. The Evidence and Evaluation for Improvement Team carried out literature searches and produced evidence summaries for the following topics:

Exercise interventions and physical activity
Polypharmacy review
Immunisation
Primary care interventions
Community geriatric services
Lifestyle factors: physical activity diet, obesity, smoking alcohol and their relation to frailty
Nutritional interventions for the prevention and treatment of frailty
Hospital at home: admission prevention and early discharge
Reablement (including rehabilitation)
Bed-based intermediate care
Anticipatory care planning

Making the evidence accessible

We then created visual abstracts for each topic, which allow readers to compare the different interventions at a glance, and provide a route into the more detailed evidence summaries and further reading. The visual abstracts include information on the potential benefits of each intervention, evidence quality, costs, and frailty level:

Reablement summary — Reablement evidence summary

We hope that this document will help Health and Social Care Partnerships to compare different interventions for frailty and the evidence behind them, and to consider which interventions could make a difference for people with frailty in their local areas.

You can access the report, Living Well in Communities with Frailty: evidence for what works by clicking on the document image below:

Introducing Maxine Jones

Published on 8 March 20188 March 2018 by Living Well In CommunitiesLeave a comment

I’ve had a long career in generalist primary care practice management, so stepping into a new role as Fife’s palliative care improvement advisor may have seemed at first like a leap into unfamiliar, specialist territory.

But, as one doctor said to me, palliative care is the bread and butter of primary care.

Both services share a deep-rooted holistic philosophy that deals with the emotional, social, practical and spiritual aspects of health and well-being, as well as the medical management of illness.

So, for me, a move to palliative care felt like a home coming.

Improvement work

I’m working with Fife’s health and social care partnership to realise the Scottish Government’s vision, that by 2021 everyone who needs palliative care will have access to it.

Our aim is to innovate and improve the identification and care coordination for people who may benefit from palliative care.

What people want is support to live well, safely and for longer in their usual place of residence. What people want is to have quick and easy access to responsive services and trusted care providers when they need them. These principals are universal to both primary and palliative care.

Some of our improvement work will focus on developing palliative care in the community, with providers that people know well. This will extend identification beyond those with cancer. Anyone living with long term conditions and growing frailty would benefit from early palliative care.

But identification is only part of the story.

As important is the coordination of responsive, person-centered services. Services that are delivered through closer, enhanced multi-disciplinary team working. Services that are nearer to people. Services that are geared towards improving continuity between people and their care providers.

You’ll hear more about my work in the coming months. I’d be delighted to learn from your community palliative care initiatives, and to hear your suggestions for improving identification and coordination of palliative care.

Please do get in touch.

Testing the eFI in Scotland: focus on Midlock GP practice

Published on 15 August 201727 March 2020 by Living Well In CommunitiesLeave a comment

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. Continue reading “Testing the eFI in Scotland: focus on Midlock GP practice” →

Update From The High Resource Individuals Roundtable

Published on 27 May 201610 June 2016 by Living Well In CommunitiesLeave a comment

HRI 1 PNG

(Source: Information Services Division Integrated Resource Framework. Data from 2012/13)

Representatives from the Scottish Government, National Services Scotland, Health Boards, Care Inspectorate, Healthcare Improvement Scotland and Health Scotland got together on 11th May to discuss the work taking place around High Resource Individuals (HRIs) across the country.

Background

In Scotland, a small number of people use a high percentage of hospital and community prescribing resources and inpatient bed days. By focussing on people with a high level of need there is potential to better understand and align the resources used, manage service capacity and demand, and ultimately improve care pathways for those that require the most support.

2020 Vision

Starting with the principles of the Scottish Governments 2020 Vision – that everyone is able to live longer healthier lives at home, or in a homely setting – the group aimed to set out clear objectives and actions for these HRI projects, such as:

supporting practical, independent living
ensuring care is person-centred
fostering a culture of improvement
effective and efficient use of resources

Presentations & Workshop

A number of short presentations highlighted some of the work currently taking place, sparking discussion on potential values and challenges so far. Continue reading “Update From The High Resource Individuals Roundtable” →