STACCATO Stow Anticipatory Care Community Assessment Tool

1. STACCATOStow Anticipatory Care Community Assessment Tool Dr Paul Cormie Sandra Pratt NHS Borders

2. What is it? • Computer based assessment tool for comprehensive functional and social assessment in patient’s home • 3 scenarios: • Current situation • Patient unwell • Carer unavailable • Risk prediction • Decision support software to enable consistency in addressing unmet need and anticipatory care planning • Information directory individual to each patient

3. The aims … • Preventing crises: • falls, • carer stress, • nutrition, • aspiration (pneumonia & UTI) • Preventing admission if a crisis arises: • Predict problems likely to arise if patient or their carer becomes unwell – logical approach to anticipatory care planning

4. The aims … • Improving discharge planning should admission be necessary – the next step: • Detailed information on functional and social status prior to the problem resulting in admission • Optimal use of health care professionals in hospital • Discharge planning starting within 24 hours of admission • Communication tool with primary care

5. Progress so far… • Rolled out as LES across NHS Borders – all GP practices opted in • Full Social Work engagement – adapted their IT system to host assessments & collect evaluation data • Out of Hours – storing assessments on shared folder in hospital & noting availability on NHS24 record • Voluntary Organisations fully involved – Neighbourhood Links, PRTC, BIAS

6. Funding….. • eHealth LTC funding: • 13 laptops for use by primary care teams in NHS Borders to carry out the patient assessments in their own home. • Provide backfill for the District Nurse on the project team to carry out training on the use of the tool in each of the primary care teams in NHS Borders • Enable a quantitative evaluation of the effectiveness of the tool

7. Other Funding … • NHS Borders: • Anticipatory Care Local Enhanced Service (GPs) & additional resource for district nurses • Change Fund: • additional social care including Bordercare, voluntary organisations, • Scottish Govt: • qualitative evaluation through University of Edinburgh 2012 • Endless amounts of Paul’s time….

8. Challenges …. • IM&T: configuration of laptops; information sharing with OOHs and Social Work; • DN access to Social Work IT system – practicalities • Communication– making sure everyone is in the loop, engages & understands • Managing anxiety about: • potential impact on DN capacity • competency with use of IT • Changing working practice

9. Evaluation … • Number of ACPs in place • Number of plans activated; times activated & outcomes • Numbers admitted / readmitted (longer timescale) • Identification of unmet need & additional care / services needed to support at home • Related referrals to voluntary organisations • Feedback from DNs: use of assessment tool & process; activation of ACPs • Patient & carer feedback • Longer term qualitative evaluation (Edinburgh University)

10. Future developments • More detailed social care planning section • Hospital discharge planning section • Care Home assessment • Tentative plans for a polypharmacy risk assessment section