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Perth & Kinross

Perth & Kinross. Intermediate Care Demonstrator Site. Integrated Locality Working. Voluntary Sector Working. Carers Support. Outcome Focussed Assessment. Immediate Discharge Services. Stepdown. Direct Access to Services Prevention. Self Management LTC. Crisis Care Team P&K. Virtual Ward.

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Perth & Kinross

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  1. Perth & Kinross Intermediate Care Demonstrator Site

  2. Integrated Locality Working Voluntary Sector Working Carers Support Outcome Focussed Assessment Immediate Discharge Services Stepdown Direct Access to Services Prevention Self Management LTC Crisis Care Team P&K Virtual Ward EMERGING SERVICE MODEL Acute medical Discharge Hospital to Home WRVS Acute Care CRT Rehab Hub Services (24 hours) ICP Housing with Care Community Hospitals Planned Care Admissions Care Co-ordination

  3. Aim of Project • Define and test the contribution that short term intermediate care services can support improved outcomes for those people living with dementia by providing • Transitional Care at Home • Education & Training to Care Homes and Care staff

  4. Objectives of Demonstrator Site • Design and deliver an active education and awareness training programme for care homes, health and social care staff with an emphasis on: • Early Detection of dementia • Reduction in acute hospital admissions from care homes. • Behaviour management techniques • Increasing dementia awareness in acute services. 2. Pilot a new type of intermediate care service that ensures • An Enablement approach to patient care • Timely access to services eg telecare, medication review, equipment • Timely discharge from hospital • Prevention of readmission

  5. Transitional Care at Home Team • Perth City • Commenced June 2009 • Multi disciplinary team with mental health expertise • Inclusive model of care • 1 WTE Registered Mental Health Nurse (Mon-Fri 8.30 am to 4.30 pm) • 3 WTE Social Care Officers (7 days 7.30 am to 10 pm) • Consultant Psychiatrist (as and when required) • Mental Health Occupational Therapist (as and when required) • Pharmacy (as and when required)

  6. Interface with Other Services

  7. Workforce Development • Education and Training to Care Home Staff • Stirling Dementia Centre • 2 day facilitator Training course • 6 month reflective practice training for 8 carers • Acute sector training (In house) • Dementia • Delirium • Behavioural & Psychological Symptoms of Dementia • Social Care Officer Training (In house) • Dementia, Delirium, Behaviour Management • Enabling rehabilitative approach - Medication management • Basic Nursing Skills

  8. User & Carer Involvement • Patient Centred Service • Carer representation on Steering Group • User / Carer Choice • User & Carer Satisfaction Questionnaires • Carers Chronicles

  9. Patient / Carer Comments “I’ve felt much more relaxed, my stress levels have dropped since service has started.” - Daughter “She’s always been against having carers, however, she has accepted them well.” Husband “The carers have been the best so helpful.” Patient “What a difference since she has accepted the care coming in, she is more pleasant, less paranoid, not disturbing her neighbours and I have not been alerted during the night, I’m enjoying the respite.” - Warden “Everyone on the service has been so good, we will miss you.” - Wife “Scott (carer) is a scream.” Patient “I think this is a much needed service.” Patient

  10. Quality & Evaluation • Better support to carers (Community Care Outcome) • Reduction in emergency inpatient bed days (HEAT) • Reduction in Delayed Discharges and length of stay (Community Care Outcome) • Increase number of people with complex needs receiving care at home (HEAT) • Support improvement in early diagnosis and management of patients with a dementia (HEAT) • Reduce admissions to acute from care homes • Improvement in healthcare experience (HEAT) • Support people at home for longer

  11. 9 discharges to service 1 community admission 1 patient readmitted to hospital IoRN & MMSE scores completed on admission, discharge and at 3 months 4 patients with improved IoRN score on discharge 4 patients with improved MMSE Scores on discharge Quietcare system x 2 All patients seen by Pharmacist for Medication Review ALOS on service 27 days Reduction in care package on discharge from service 4 patients 2 patients required no service post intervention Progress

  12. NEXT STEPS • Review the outcomes to measure effectiveness of the project • Report to CHP Committee • Report to Housing & Community Care Committee • Publish paper in journal • Secure funding for continuation • Promote service model nationally

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