Demonstrating Impact Aberdeenshire CHP & Council

1. Demonstrating ImpactAberdeenshire CHP & Council Linda Reid Project Manager (Integration H&C)

2. Joint Performance Framework • OPSOG had an Action Plan and monitoring process prior to Change Plan • Modified for Change Plan • Now has JCS Action Plan and JPF • Template updated for each meeting • Not all measures recorded with same frequency, tends to be delay in reporting

3. Measures • Measures mostly still outputs eg bed days, care home places, telecare but target driven • Outcomes personal improving some challenge to get strategic • Softer data updates from all work streams reviewed in sub groups or OPSOG • Funding can be granted, removed, increased, extended on data presented

4. At a Glance Score Card • For last 2 years • Issued monthly • 25 measures for CHP Includes data relating to • Heat targets • Bed Days • Delayed Discharges

5. Prevention: Signposting • The service has used the Warwick-Edinburgh mental wellbeing scale (WEMWBS) to gauge the ultimate effect of its interventions on those who use its services and some startling results have emerged. • Service users reported improved mental wellbeing with significant drops in GP visits and use and/or strength of prescription drugs. • This shows the project supports the achievement of personal outcomes for people as reported by those people and also system/service outcomes, that is changes in the pattern of individuals use of other services.

6. Prevention • Anticipatory Care Planning 10.3% reduction in EBDs for practices using ACPs compared to 2.5% reduction for other practices. Equals 33 less beds £3.12m. Now in Scottish GP Contract • Point of Care Testing 4 months in 3 centres 51 patients screened, prevented admission or transfer in 41. If 7 centres working well could prevent at least 300 admissions or transfers.

7. Prevention • Using BNP avoid 300 referrals for echocardiography, and D-dimer halves number of patients referred to outpatient DVT services. • Heart Failure Nurses 69 hours of nurse time per week Prevented 62 admissions 236 primary care contacts avoided

8. Rehabilitation • MD REACH team established 3 models • Data evidencing reduced or stabilised amount of care at end of work • For some work achieved care previously rejected leading to repeat crises/admissions • RGU commissioned to evaluate fully to inform roll out

9. Improving Long Term Care • Training in Dementia Care across sectors • Note numbers trained • Care Inspectorate Grades rising • Soft data Staff increased job satisfaction & understanding Better standards of dementia care Use of medication for behaviour modification is closely scrutinised and it appears to have reduced.

10. Sheltered and Extra Care Housing • Thorough work to measure dependency and service models with costs • Extensive consultation • New models introduced in VSH &SH • Decision to convert SH complexes to VSH to offer increased choice in each locality • Evidence VSH takes most to end of life • Significantly shifts balance of care

11. Joint Equipment Store • JES developed based on analysis of stores, delivery times, cleansing and ordering across Council area and Health • Immediate increase in efficiency and effectiveness • Stats re workload & DD evidence to Change Fund for increase in staff. • Council & Health staff will shortly order off Health Code to save duplication.

12. Future Work • Examination of requirement for Care Home Beds based on current projections • Plan to share with Planners and Providers • Challenge Commissioning Quality versus Choice Guidance