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Bristol s Promoting Independence Team

26/03/2012. 2. What are we aiming to do?. Reduce the number of older people experiencing crisesIncrease the engagement of local communities in supporting older peopleExplore the use of AT to help maintain independencePromote integration across health and social services. 26/03/2012. 3. How?. Piloting 2 Promoting Independence Teams in two areas of BristolMulti-disciplinary, including mental healthBoth areas have have high levels of deprivation, one has large BME populationPump priming money for local voluntary organisations.

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Bristol s Promoting Independence Team

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    1. 27/03/2012 1 Bristol’s Promoting Independence Team Sue Cheasley, Team Manager Maya Bimson, Transformation Programme Manager

    2. 27/03/2012 2 What are we aiming to do? Reduce the number of older people experiencing crises Increase the engagement of local communities in supporting older people Explore the use of AT to help maintain independence Promote integration across health and social services

    3. 27/03/2012 3 How? Piloting 2 Promoting Independence Teams in two areas of Bristol Multi-disciplinary, including mental health Both areas have have high levels of deprivation, one has large BME population Pump priming money for local voluntary organisations

    4. 27/03/2012 4 Who are in the teams? Community Nurse for Older People Assessment and Review Coordinator Community Mental Health Nurse Community Development Worker Part-time manager across 2 teams

    5. 27/03/2012 5 What will the teams do? Case Finding - Ambulance Trust - A&E - GPs - Care Direct Take referrals from: - professionals – inc vol sector - older people and their carers

    6. 27/03/2012 6 Eligibility criteria The teams will provide a service for vulnerable older people, aged 65 or over, who may not be receiving a community based health or social care service. They must have non-acute health and social care needs that do not require a rapid response.  

    7. 27/03/2012 7 What factors might prompt a referral? Memory problems/ dementia Mental health problems & depression Falls Frail Elderly More than 4 medications Social isolation Bereavement Alcohol and other dependency issues Financial worries

    8. 27/03/2012 8 Case Management A screening telephone call An assessment visit Agreeing priorities with the user Developing an action plan Directly arranging the provision of services if not eligible under FACS

    9. 27/03/2012 9 Case Management Making appropriate referrals Actively monitoring the progress of any referrals and service delivery arrangements with a focus on ‘making things happen’ 6 month review

    10. 27/03/2012 10 Case Study Flo approached one of the Team’s workers at lunch club She wanted to discuss accessing the community bus to enable her to use the local shops for fresh vegetables as she is diabetic During a general conversation she mentioned that she was managing with difficulty

    11. 27/03/2012 11 Flo was living in a council house where she had lived for 60 years She was about to have her electricity cut off • She had fallen twice in the garden due to uneven paths and slipped off the last stair in the house and hit her head in the last few days She lived in one very cluttered room downstairs. She sleeps in this room with a gas fire sometimes left on all night

    12. 27/03/2012 12 She accessed her toilet upstairs on her hands and knees Her kitchen is in a very bad state of disrepair • The windows are ill fitting and stuffed with rags to prevent draughts All laundry is done by hand, dried in bathroom and then aired on gas fire • During the winter Flo does not change her bedding as she is unable to wash and dry it.

    13. 27/03/2012 13 Actions Taken: Falls Screening Tool identified 4 triggers which led to full falls assessment Fast track referral to Independent Living Service led to hand rails being installed within 3 weeks The team’s community nurse sorted her medication problems Energy payment scheme set up and Flo added to vulnerable person list

    14. 27/03/2012 14 Housing Department contacted and surveyor’s visit led to Flo being offered central heating, repairs to path, new kitchen and new windows Helped to use the Community Bus to access shops Laundry services explored Benefits checked for full entitlement Eye Hospital visits for cataract Dentist visit set up – her first for 60 years! Option of sheltered housing explored

    15. 27/03/2012 15 Evaluation of the project Both qualitative and quantitative targets established and data collected on Statistical Package for Social Sciences (SPSS) Continual performance management to ensure targets are met Overall evaluation by the University of West of England

    16. 27/03/2012 16 Sustaining the Change Using the evaluation to disinvest and re-invest Using the pilot to build capacity in the independent sector Using the experience to reconfigure existing health and social services teams

    17. 27/03/2012 17

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