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Change Fund 2013/14 – Mid-Year Review

Dear colleagues

The main purpose of this year’s mid-year Change Fund survey is to share examples of how local partnerships have deployed their Change Fund to make a difference to the lives of older people and their carers across Scotland. The JIT will use this additional insight to understand what is working well, to share learning about the impact of successful innovations, and to identify areas of work that may require further improvement support in order to make progress on joint strategic commissioning and integration. An overview report will be shared with the Health and Community Care Delivery Group and the Ministerial Strategic Group.

We ask you to describe the learning from at least one initiative that you have taken forward under each pillar of the RCOP pathway. We appreciate that full evidence of impact may not yet be available for some of these initiatives. Therefore your comments should describe achieved or anticipated outcomes and gains, along with your learning to date and any implications for future investment decisions.

As in previous years, we have asked you to report spend against the pillars of the RCOP pathway. This is to help track the progressive shift in focus and investment towards preventative and anticipatory care.

We realise that it will take time to fully realise this shift and to show measurable impact on outcomes at scale. Therefore, we invite you to complete a self-assessment proforma to reflect on the extent to which specific approaches and improvements have been spread locally and to understand where, and when, further gains can be anticipated through joint commissioning. This will also enable JIT to identify those initiatives that require further support for implementation.

Recognising the growing importance of accessing and using data and information to inform decision making, we have also included a specific question about this in the 2013/14 mid-year review.

Your responses will inform the on-going improvement support for Reshaping Care and Integration provided by JIT and our partner organisations.

Please send your response to [email protected] by Friday 27th

September. Thank you for taking the time to complete this mid-year review.

DR MARGARET WHORISKEYDirector, Joint Improvement Team

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mailto:[email protected]

Contact Details

To ensure our records are up-to-date, please complete for all four partners:

Strategic Lead

Name Peter GabbitasJob Title Director of Health and Social CareEmail Address [email protected] Telephone # 0131 553 8201

Operational Lead

Name Caroline ClarkJob Title Planning and Commissioning Officer, Older PeopleEmail Address [email protected] # 0131 469 3220

Third Sector Lead

Name Ian BrookeJob Title Deputy Director, Edinburgh Voluntary Organisations

Council (EVOC)Email Address [email protected] Telephone # 0131 555 9100

Independent Sector Lead(s)

Name Rene Rigby/ Peter McCormickJob Title Development Officer/ Scottish Care Local Branch

ChairEmail Address [email protected] /

[email protected] Telephone # 07568335448/

Other Key Contacts (if any – e.g. overall Project Managers/Officers, Development Managers/Officers etc.)

NameJob TitleEmail AddressTelephone #

NameJob TitleEmail AddressTelephone #

Name

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Job TitleEmail AddressTelephone #

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Change Fund 2013/14 – Mid-Year Review

Partnership EdinburghContact Name(s) & Job Title(s)

Caroline Clark, Planning and Commissioning Officer, Older People

Email Address [email protected] Telephone # 0131 469 3220Date of Completion

20 September 2013

1. Examples of impact

Please complete a case study template (Annex 1) describing at least one achievement that your partnership has made through use of the Change Fund for each of the Reshaping Care Pathway workstreams (i.e. we would like at least 5 in total to be submitted):

Preventative and Anticipatory Care – Innovation Fund, Community Connecting, Community Transport, Resilience Fund (inc Participatory Budgeting),

Proactive Care and Support at Home – Day Services, Re-ablement, Care at Home, Overnight Service, Medication Procedures, Telecare, Telehealth

Effective Care at Times of Transition – COMPASS, Carers Hospital Discharge Service (and MECOPP), Community Therapy (Int Care, ESS, S&LT), Medication Review, Dementia post-diagnostic support,

Hospital and Care Home(s)- Dementia Training, Small Investment Fund, Care Home Liaison

Enablers – Making it Clear, Dementia Campaign, My Home Life,

Each case study should be no more than one page long, with at least one of the case studies highlighting either a direct or an indirect impact on carers. Question 7 below contains short descriptors of interventions in the pathway.

2. Learning from what hasn’t worked as well as anticipated

The Change Fund has been an opportunity for Partnerships to explore innovations that are ‘Proof of Concept’ or ‘Tests of Change’. Please describe any shareable learning gained from initiatives where a decision not to continue has been taken – e.g. where barriers to progress were encountered or the initiative was not found to be effective.

The Edinburgh Change Fund Partnership has continually reviewed the investments made and information from ongoing evaluation is used to inform future funding decisions. For many investments, more time is required in order to demonstrate the impact of the work. The examples below show how learning has been used from projects to inform further work.

Enhanced Supported Discharge

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A twelve week test period involved the supported discharge of selected Medicine of the Elderly, Acute Stroke & Respiratory patients at the Royal Infirmary of Edinburgh. Findings from the project included that the predominant interventions required to support the discharge of patients were not of a secondary care nature, but were from the support of Allied Health Professionals, assessment, therapeutic and social care teams. The findings from this work have shaped further work of the Change Fund, including the development of the COMPASS model and ongoing communications and engagement activity to build understanding and confidence between hospital and community based teams.

Innovation FundDecisions for allocating the Innovation Fund were made by a panel which included NHS, Council and an independent representative. The panel closely reviewed the progress of the projects and made decisions around the continued funding for 2013/14 (at the same level, reduced, or increased) and suggestions for how projects could be tweaked or refocused were made. Funding for one project, Here’s a Hand, was not continued for 2013/14 through mutual agreement due to low levels of take up experienced by the project. Raising awareness of projects in order to maximise referrals has been an issue for a number of projects and the partnership has provided communications support including printing of materials and hosting information events.

Small projects A number of small projects have experienced issues in terms of the recruitment and retention of staff. These issues have caused challenges for projects across all sectors that have been required to implement within short time scales and then quickly demonstrate the impact they are having. Small projects recruiting 2-3 staff members are particularly vulnerable and the success or otherwise of a project often relies on the individuals recruited. A number of projects have experienced some or all staff moving on for a range of reasons, often out-with the control of the organisation, and the implementation of the service has been halted. In these circumstances, the Change Fund Core Group has agreed to continue funding for a further year in order to allow the projects to collect data to inform the evaluation process.

3. Option Appraisal

Please describe any option appraisal approaches used to decide Change Fund investment priorities – e.g. whether applied to all / only selected initiatives and who was involved.

The initial process of funding allocation included a series of engagement events and workshops. All proposals were made using a standard template which asked for information about the proposed service including additionality that would be delivered, intended outcomes and exit strategies. In some areas, allocations were made to a theme or to deliver an outcome, but further work was required to determine how the allocation would be best used to achieve this. Some specific examples for how options were appraised are provided below:

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Dementia Training in Care HomesAn allocation was made to enhance dementia training provided in all care homes in Edinburgh (independent and Council homes). The initial proposal was based on a particular method of delivery, but further work was then carried out to appraise other options. The timing of this work coincided with national developments, including the publication of the national Dementia Strategy, based on the Promoting Excellence framework. A Training Partnership has been developed to include NHS, Council, Scottish Care and EVOC who are undertaking further work to understand what training is already provided in care homes, what additional requirements they have and how these would best be met. This is a resource intensive process but aims to deliver best value for the Change Fund Partnership and the most significant and sustainable approach for care homes.

Canny wi’ Cash – Older People deciding on grants for Older PeopleAn allocation of £35k has been made for a small grants fund (up to £1,500) for very small community groups for older people across the city. Participatory budgeting will be used so that older people vote and decide which applications should be funded. EVOC are leading this work and a team of trained facilitators will go out to where older people are - lunch clubs, day centres etc - to gather their views over a 'voting fortnight' in October. Using this creative approach, we hope we can reach out to 1,000 voices of older people across Edinburgh.

Community TransportCommunity Transport was identified as a priority area for investment following workshops with the voluntary sector and service users. A report commissioned by EVOC also made recommendations for how funding allocated to the ‘community capacity building’ theme should be prioritised, and community transport was one of four priority areas. Deciding how the community transport allocation be used has been very challenging. It is a complex area with many stakeholders and through a series of engagement it became apparent that a quick solution would not be achieved. The Change Fund allocation has helped to highlight the need for a comprehensive review and agreed strategic approach for community transport in order to meet the future needs of older people in Edinburgh. Some of the funding has been used to support a review of Community and Accessible Transport which is now underway and it is hoped that recommendations from the review will inform how the remaining funding should best be allocated.

4. Use of Data and Information

Please describe your local progress and any barriers to effective use of data and information between partners (both within and out with the statutory sector).

Data and information has been an important part of the Change Fund work. Sharing information has proven to important on a number of levels including: the sharing of service user data across systems and organisations to improve joined up care for the older person, developing meaningful data to demonstrate the impact of the Change Fund across all partners, and sharing information about the wide range of services and support available for older people in Edinburgh. Some specific examples are provided below:

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COMPASS – information sharingRegular Multi-Disciplinary Team Meetings (MDTMs) are a key component of the COMPASS model. The MDTM discussions have highlighted the challenges that multiple systems present for practitioners in trying to deliver more integrated care around the older person. Both long and short term solutions to these challenges continue to be developed.

Change Fund EvaluationDeveloping a partnership approach to evaluation has been a positive achievement for the Change Fund in Edinburgh. All partners face the challenge of collecting meaningful data to evidence the impact that the Change Fund is having. Bringing partners together has highlighted the different perspectives on what ‘impact’ means eg the impact on high level system measures such as emergency admissions to hospital and the impact on the quality of life older people. The Evaluation Framework aims to provide a range of quantitative and qualitative data, including service volumes and outputs, individual and service level outcomes, case studies and whole system measures. The data is tailored to suit the audience to which it is being presented but it is hoped that through increased partnership working a shared perspective will continue to be developed.

Information about services and support available for older peopleIncreasing awareness and understanding of services available for older people to support them within the community has been a key focus for the Change Fund in Edinburgh. There has been significant engagement with a wide range of stakeholder groups including GPs, acute clinicians, care home providers and the voluntary sector. Initiatives have included:

a series of Information Days for older people, their carers and health and social care professionals to raise awareness of preventative, locally based services

a directory of services has been widely distributed to clinical and social work professional staff, to raise awareness of the range of services available, particularly those that focus on prevention and rehabilitation and that are based in the community

a comprehensive online directory of services is currently being developed seminars have been held on specific developments such as step down and

dementia, with audiences including GPs, primary and secondary care, social care and Elected Members.

5. Improvement support

Please provide details of any support you would welcome.

There is a need to continue to share good practice across partnerships and support to do this would be welcomed. Particular areas of interest include:

national level support in relation to what kind of evidence is likely to be effective in demonstrating impact

examples of initiatives that are working well in other areas and support to

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obtain detailed information about relevant initiatives examples of ways that other areas are approaching the challenge of data

collection and aggregation of individual case data to measure the impact of services

examples of how other partnerships are embedding personal outcomes and practical support and suggestions for how this is done locally.

6. Budget 2013/14

Please insert details of your 2013/14 Change Fund budget and the proportion of spend aligned to each of these 5 workstreams:

2011/12 2012/13 2013/14SG Allocation £ £ £Additional Local Resources (if any)

£ £ £

Carry Forward N/A £ £Total Allocation £ £ £Year-end Spend £ £ £

(anticipated)

Anticipated Carry Forward to 2014/15 £

Direct spend on carers (year-end spend)

N/A £ £(anticipated)

Indirect spend on carers (year-end spend)

N/A £ £(anticipated)

Preventative and Anticipatory Care

Proactive Care and Support at Home

Effective Care at Times of Transition

Hospital and Care Home(s)

Enablers

Total (should equal 100%)

2011/12 (year-end spend)

% % % % % %

2012/13 (year-end spend)

% % % % % %

2013/14 (anticipated year end spend)

% % % % % %

7. Assessment of Spread

The Reshaping Care Pathway represents 4 ‘bundles’ of interventions, approaches or actions and the related enablers which collectively improve outcomes for older people. As you take forward Joint Commissioning, it is important to understand the extent to which you have spread new approaches and improvements so that you can understand where and when future gains can be anticipated.

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Therefore we invite Partnerships to complete a self-assessment of spread as at September 2013 by assigning a position statement 0-5 to each approach or intervention in the pathway.

Spread Value

Self-Assessment Position Statement

0 No agreed plan to implement the approach / intervention / improvement action

1 Agreed plan to take forward the approach / intervention / improvement action but not yet began to implement

2 Testing / implementing the approach / intervention / improvement action in a minority of localities / sites / teams / older people / carers

3 The approach / intervention / improvement action has spread to most localities / sites / teams / older people / carers

4 The approach / intervention / improvement action has spread to all localities / sites / teams / older people / carers but is not yet fully embedded in routine practice

5 The approach / intervention / improvement action is fully embedded in all localities / sites / teams / older people / carers and there is an agreed plan to sustain this

Preventative and Anticipatory Care Value (0-5)

Build social networks and opportunities for participation

We are mobilising community support through volunteering, building community capacity, collaborations and social enterprises that promote participation and meaningful activity for older people living at home and in care homes.

2/3

Early diagnosis of dementia

We continue to work to increase the number of people with dementia who have a diagnosis as this improves access to support and services for the family.

2

Prevention of Falls and Fractures

The Partnership is implementing the recommendations of Up and About: a whole system pathway for the prevention and management of falls and fragility fractures.

4

Information & Support for Self-Management & Self-Directed Support

Practitioners and services signpost older people towards community and third sector resources that help them to stay well, to manage their conditions and provide useful and accessible information and advice on the choices they have about their future care, support and housing. This includes post diagnostic support for people affected by dementia and information and support required to adopt personal budgets.

2/3

Prediction of risk of recurrent admissions

Community health and social care teams routinely use a risk prediction tool (e.g. SPARRA) and local health and social care data and intelligence to identify older people who are frail and at greatest risk of emergency admission to hospital or care home.

2

Anticipatory Care Planning

Care providers support frail older people and their carers to develop Anticipatory Care Plans (ACPs): a summary or shared record of the preferred actions, interventions and responses in the event of an anticipated deterioration in the health of the person or their carer.

2

Support for carers

Our health and care staff routinely identify carers and are able to signpost them to information, advice and support from social work, carers centres and other agencies to help them to stay well and be supported to continue in their role.

4

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Preventative and Anticipatory Care Value (0-5)

Suitable and varied housing and housing support

We are investing in handyperson services, housing support, making better use of our existing stock of sheltered housing and developing new specialist provision to help older people maintain their independence and reduce the risk of accidents at home.

4

Proactive Care and Support at Home Value (0-5)

Responsive flexible, self-directed home care

All providers of care and support at home adopt a “doing with” approach and formulate packages of care and support around the individual’s personal goals. This includes the opportunity to adopt personal budgets for care and support.

3

Integrated Case/Care Management

Multi-disciplinary community health and social care teams adopt an integrated case / care management approach to monitor and proactively support frail older people with complex and changing needs at greatest risk of emergency admission to hospital or care home.

3

Carer Support and Respite

We provide opportunities for short breaks to help carers continue to provide care, helping reduce isolation, providing a better quality of life and maintaining carers’ health and wellbeing.

4

Rapid access to equipment

There is effective and timely access to health and social care equipment and adaptations and this is an integral part of mainstream community care assessment and service provision.

5

Timely adaptations, including housing adaptations

We have streamlined access to adaptations and alterations which help older people to maintain their independence at home.

5

TelehealthcareThe partnership provides remote monitoring and assistive technology for older people with complex care and support needs who require this technology to remain supported in their own home.

4

Effective Care at Times of Transition Value (0-5)

Reablement & Rehabilitation

Health and care practitioners adopt an enabling approach and all providers have a focus on maintaining independence, recovery, rehabilitation and re-ablement.

4

Specialist clinical advice for community teams

Primary and community health and care staff, including voluntary and independent sector partners, are supported by access to a range of specialist practitioners for advice on common important conditions in older people such as dementia, continence, nutrition and tissue viability.

5

NHS24, SAS and Out of Hours access ACPs

Community teams share essential information from ACPs (e.g. electronic Key Information Summary) with local emergency and out of hours services and with SAS and NHS24.

2

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Effective Care at Times of Transition Value (0-5)

Range of Intermediate Care alternatives to emergency admission

Working alongside NHS24, SAS and Out of Hours services we provide rapid access to a range of enabling assessment and treatment services at home, in minor injuries units, day hospitals, community hospitals and care homes as safe and effective alternatives to acute hospital admissions and to support timely discharge.

3

Responsive and flexible palliative care

We provide timely access to community based support for palliative and end of life care to increase the proportion of older people who are able to die at home or in their preferred place of care.

3

Support for carers

We promote shared decision making and make sure that carers are informed and supported to help them continue in their role when the health of the person they care for deteriorates or they move to another care setting.

4

Medicines Management

Joint working between GPs, community pharmacists, mental health teams and geriatricians reduces polypharmacy for older people through mindful prescribing, review and reconciliation of medicines and use of pharmaceutical care plans. We support older people and their carers to administer and take medication safely.

4

Access to range of housing options

The range of intermediate care services provided includes timely accessible housing options for people whose functional ability has acutely declined.

3

Hospital and Care Home(s) Value (0-5)

Urgent triage to identify frail older people

Pathways through A&E and admissions wards are configured to identify frail older people with physical, functional and cognitive impairments who will benefit from coordinated comprehensive geriatric assessment.

4

Early assessment and rehab in appropriate specialist unit

Frail older people with physical, functional and cognitive impairments and those who have fallen are ‘pulled’ to access multi-professional Comprehensive Geriatric Assessment within 24 hours of emergency admission to hospital.

2/3

Prevention and treatment of delirium

Pathways through acute hospitals minimise boarding for frail older people and care staff are trained to prevent, detect and effectively manage delirium.

3

4Effective and timely discharge home or to intermediate care

All partners work together and with Scottish Ambulance Service to optimise use of estimated date of discharge, improve discharge planning and eradicate delayed discharges, including delays in short stay specialty beds and for Adults with Incapacity.

4

Medicine reconciliation and reviews

Medicine reconciliation is routinely undertaken for older people on admission and at discharge from hospital and care homes, and antipsychotic prescribing is minimised.

3

Carers as equal partners

We identify the carer at an early stage when the person is admitted to hospital and ensure that the carer is involved in the care, rehabilitation and discharge planning.

2

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Hospital and Care Home(s) Value (0-5)

Specialist clinical support for care homes

We provide specialist clinical support to enable care homes to have a greater role in intermediate care and to support staff to care for older people with dementia and palliative / end of life care needs.

3

Enablers Value (0-5)

Outcomes-focussed assessment

Our providers of care and support deliver personalised care through assessments which focus on personal outcomes and goals agreed with the older person (and their unpaid carer).

3

Co-productionServices are planned and delivered in an equal and reciprocal relationship between professionals, people using services, their families and the community.

4

Technology/eHealth/Data Sharing

We routinely share information across professionals and teams in line with agreed data sharing protocols and using the capability of emerging technology.

3

Workforce Development/Skill Mix/Integrated Working

We are developing a multi-professional workforce that is integrated, capable and fit for the future with core generic skills and appropriate specialist competencies.

3/4

Organisational Development and Improvement Support

We engage and communicate effectively with all partners, with our workforce and the public, and collaborate across professions and sectors to strengthen strategic leadership for change and to build improvement capacity and capability.

5

Information and Evaluation

We routinely use measurement for improvement and feedback performance measures to our staff and to the public to lever and assure quality.

4

Commissioning and Integrated Resource Framework

Statutory, community, third and independent sectors, users, carers, providers and commissioners of care come together to agree long term service development and investment proposals including where and how resources should shift from current services and care models to new arrangements.

We are using the Integrated Resource Framework to lever a shift in the totality of the partnership spend on service and support for older people.

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8. Any additional comments?

Thank you for taking the time to complete this mid-year review. Please return this template, along with at least 5 case studies using the pro-forma in Annex 1, to [email protected] by Friday 27 September 2013.

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Annex 1 – Examples of Impact

As per Question 1, please complete the following template for each example of achievement your partnership has made through use of the Change Fund for each of the Reshaping Care Pathway workstreams. We would like at least one example for each workstream, with at least one of the case studies highlighting either a direct or an indirect impact on carers.

Note – This paper is designed to show highlights and not a full case study and should be no more than one page long, allowing readers to have access to further information, if helpful. Please remember to ‘tag’ the case study appropriately on the next page. Submitted case studies will be published on the JIT website.

Reshaping Care and Integration Improvement NetworkPartnership Edinburgh

Name of Initiative Highlighted Community ConnectingDate of Submission 27/09/13

Primary Contact Caroline ClarkEmail [email protected] Telephone # 0131 469 3220

Pathway: Preventative and Anticipatory Care

1. SummaryPlease summarise the case study in one paragraph of no more than 100 words.

Community Connecting is a service for older people (aged 65+) living in Edinburgh. The service supports older people to build networks and links into local opportunities and activities. Volunteers are recruited, trained and supported to work with older people to identify things they would like to do and support them to start doing them.

2. What was the issue you were addressing or working on?

The service aims to reduce social isolation and support individuals to establish/ re-establish sustainable connections with their communities. People coming to the service have often lost confidence after a fall, illness or bereavement.

3. What did you do?(Intervention(s), organisations involved, when it happened, development or tools used including use of Change Fund, JIT involvement)

A Community Connecting service had previously been piloted in two areas of the city. Evaluation and feedback was positive. The Change Fund Core Group agreed to fund the development of a city wide service. A procurement exercise was carried out, led by a Project Board which included representation from all sectors. Four contracts were awarded to voluntary sector providers for each of the four sectors of the city.

4. What were the outcomes/benefits or otherwise?(What happened and what was gained or lost from this? When were the benefits realised? Would you do anything differently? What is/was your timeline?)

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The objectives of the service are to:

Enable service users to stay in their own home for longer Delay the need for access to higher levels of home/day services Provide short breaks for carers Increase or maintain the level of independence Produce a positive impact for people using the service including: building

confidence, reducing loneliness and giving older people a choice in the activities they want to get involved in.

The service aims to support 720 people per year. The contracts started on 1 October 2012 and the service is still gearing up, with 185 people supported between October 2012 and May 2013. The service providers are working with Evaluation Support Scotland to develop a consistent approach to evaluation, including evidencing individual outcomes which are at the heart of this service.

5. Additional contacts (to find out more)(People, organisations, link(s) to further information, if available)

The following short films provide further information about the Community Connecting service:

http://www.health-in-mind.org.uk/services/community-connecting.html

and

http://www.youtube.com/watch?v=iiPxePMvJqY&feature=c4-overview&list=UUO2SRSCUDfPuCbXBztn6_2g

For further information please contact Caroline Clark [email protected]

Once submitted, this case study will be published to the JIT website. To help users find case studies relevant to their area of interest, this case study should be tagged with the following search terms (e.g. Reshaping care, re-ablement, community capacity, third sector, preventing admissions, intermediate care)

In order to help us best sort the case studies please enter a Y into each and every box you think this applies to, being cognisant of the primary pathway chosen on the previous page:

Preventative and

Anticipatory Care

Case Study

Proactive Care and Support at

Home

Case Study


Case Study


Case Study


Y








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http://www.health-in-mind.org.uk/services/community-connecting.html









Effective and timely discharge home or to intermediate care






TelehealthcareSupport for carers


Support for carers

Y Medicines Management




Enablers

Outcomes-focussed assessment YCo-production YTechnology/eHealth/Data SharingWorkforce Development/Skill Mix/Integrated WorkingOD and Improvement SupportInformation and EvaluationCommissioning and Integrated Resource Framework

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Name of Initiative Highlighted LGBT Age Capacity Building ProjectDate of Submission 27/09/13

Primary Contact Stefan Milenkovic Email [email protected] # 0131 523 1100

Pathway: Preventative and Anticipatory Care


The project is led by the LGBT Centre for Health and Wellbeing and has two main strands:

Capacity building work with older LGBT people: to increase the engagement of older LGBT people themselves with the Age Project and enable their experiences to feed into service design and delivery; creatively use older LGBT people to link others into the project.

Capacity building work with mainstream organisations: to increase understanding and enable organisations to better meet the needs of older LGBT people and comply with the Equality Act’s general equality duties; through this work also boost referrals to LGBT Age.


Research shows that older LGBT people have greater need but are less likely to access formal care and support services.

Older LGBT people are: 2½ times more likely to live alone twice as likely to be single as they age 4½ times more likely to have no children to call upon in times of need 10 times more likely to indicate that they have no-one to call on in times of

crisis or difficulty.

There is a greater reluctance among older LGBT people to access services due to concerns over discrimination, fear of harassment and loss of privacy and the needs of LGBT older people remain largely hidden and unrecognised by health and care service providers.

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Funding for this project was allocated through the Innovation Fund (a total of over £500k allocated to community capacity building projects within the voluntary sector). A panel considered over 40 applications, 20 of which were awarded funding. The LGBT Centre for Health and Wellbeing recruited staff and managed the implementation of the project, with six monthly evaluation to the Change Fund Evaluation Group.


The project has delivered the following in its first year: identifying older LGBT people to work with establishment of a Reference Group of older LGBT people establishment of Community Champions establishment of a Professionals’ Forum awareness raising events training and workshops for a range of voluntary and statutory services film project – the film was launched on 11 September 2013 and will now be

further edited to allow use as an educational and awareness raising tool.

Key outcomes delivered include: enhancing volunteering, building community capacity and building the capacity of mainstream organisations.


Stefan Milenkovic [email protected]



Preventative and

Anticipatory Care

Case Study


Home

Case Study


Case Study


Case Study


Y






Specialist clinical advice for community

Early assessment and rehab in appropriate

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teams specialist unit






Y Rapid access to equipment










Support for carers





Enablers

Outcomes-focussed assessmentCo-production YTechnology/eHealth/Data SharingWorkforce Development/Skill Mix/Integrated Working YOD and Improvement Support YInformation and EvaluationCommissioning and Integrated Resource Framework

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Name of Initiative Highlighted Developing a Re-ablement approach within day services for older people

Date of Submission 27/09/13

Primary Contact Doreen Copeland (Development Manager for Older People’s Day Services)

Email [email protected] Telephone # 0131 553 8453

Pathway: Proactive Care and Support at Home


The investment is being used to develop a Re-ablement approach within day care services. Four Occupational Therapists (OTs) have been recruited to work throughout both council and voluntary sector day services in Edinburgh. Two started in July 2012 initially working with council services and following their success another OT was recruited in August 2013 with one more due to start in October 2013 to help extend the work into the voluntary sector.


Work towards policy objectives and strategies, such as: Reshaping Care for Older People (2010) Live Well in Later Life, Edinburgh’s Joint Commissioning Plan (2012-2022) Integration of Health and Social Care Market Shaping Strategy(2013) Personalisation Agenda

to meet the challenge of increasing numbers of older people. Key objectives of the service are to:

Facilitate early discharge from hospital and prevent admission Maximise people’s independence to remain in the community for longer Supporting people to achieve better outcomes Reduce carer stress.


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Since July 2012 the OTs have been working in a focused way with individual service users dealing with assessments such as manual handling, mobility, feeding, access and equipment. They have been working closely with day service staff to help change the culture in day services to a Re-ablement style approach. Since March 2013, the OTs have also been training staff from the centres and have been running 14 week Cognitive Stimulation Therapy (CST) programmes working with service users with mild to moderate levels of dementia in small groups. They are rolling this out across the city.

It is working closely with the voluntary sector where OTs are rolling out their work further. This service is also linking in with Health services, Home Care Re-ablement, Intermediate Care and the Dementia Strategy.


The Re-ablement approach within day services can have a positive impact on both service users and carers by helping older people to regain life skills and maintain as independent a life as possible.

The approach has shown immediate, positive effects. There has been instant improvement in service user’s abilities and staff skills, for example the mobilising of seven people who were in wheelchairs. The OTs have been working closely with staff which has greatly helped to change the culture within day centres. These results will continue to produce short, medium and long term results for the service and the outcomes of the service users. A longer term objective is the anticipated increase in throughput to preventative services due to the Re-ablement approach and plans are underway to facilitate this. CST has been shown to stimulate and improve memory and cognition therefore strengthening people’s resources and allowing them to function at the maximum capacity. This fits with the ethos of Re-ablement. CST is being offered to older people through the day services as part of a structured programme. It is believed that this programme can help to reduce carer stress by supporting older people to live as independent a life in the community for longer. The service is looking into training relatives/carers in the future so they can undertake CST at home. The response from the programme group members has been very positive, one stated:

“Helps with my confidence, I’m a lot cleverer than I thought!”

Feedback from family members/carers has also been very positive. Two comments included:

“I am very happy that my mum is doing this type of group as it is something that I am trying to do with my mum at home. I see that she is brighter in mood and says that she has enjoyed the group.”

and

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“I have very much seen a difference in my mum since the group started, she is mentally brighter and her mood is brighter as well. When I speak to my mum on a Tuesday she is able to put a conversation together better. My mum has not spoken much about going to the centre before but she is now saying that she likes it and has met some nice people which is definite progress.”

Another benefit is that this has seen improved partnership working as connections and close working relationships have had to be made with Health, voluntary sector, other teams and worker types within the department, as well as service users and carers, in order to facilitate this shift in the way this service is being delivered.


This is just some of the activity that is happening in this work stream. Further information can be sought through:

Doreen Copeland (Development Manager for Older People’s Day Services) [email protected]

Yvonne Gannon (Evaluation lead) [email protected].

CST has been recommended by NICE (National Institute of Clinical Excellence). See http://www.cstdementia.com/ for more details.



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Reablement & Rehabilitation Y







Y Carer Support and Respite Y







Prediction of Timely Responsive and Medicine

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http://www.cstdementia.com/




risk of recurrent admissions

adaptations, including housing adaptations

flexible palliative care

reconciliation and reviews




Support for carers





Enablers

Outcomes-focussed assessment YCo-productionTechnology/eHealth/Data SharingWorkforce Development/Skill Mix/Integrated Working YOD and Improvement SupportInformation and EvaluationCommissioning and Integrated Resource Framework

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Name of Initiative Highlighted Medication reviewDate of Submission 27/09/13

Primary Contact Stefan McDonaldEmail [email protected] #



The investment provides additional capacity within community pharmacy to review medication packages, targeting older people who receive regular home visits to dispense medication. To objective is to rationalise and optimise medication and ensure that patients are receiving the best treatment possible in the safest way.


Evidence suggests that 50% of people with long term conditions do not use their medication as prescribed, leading to poorer health outcomes and unnecessary hospital and nursing home admissions. The largest UK analysis of adverse drug reactions (ADRs) as a cause of hospitalisation reported 5.2% of admissions being

directly related to ADRs at a projected annual cost to the NHS of £466m. Further studies indicate that ADRs are implicated in between 5-17% of unplanned admissions. In addition:

Patients with greater than nine medications have at least 22 percent incidence of medication errors which contribute to adverse reactions and hospitalization. (Ahrens et.al, 2002)

From 10-31 percent of all hospitalisations and up to 45 percent of re-admissions among the elderly can be attributed to medication related complications. (HMO Workgroup on Care Management 2002)

A study by the Veteran’s Administration demonstrated a 30 percent improvement in medication compliance after telehealth implementation. (Ryan, et. al 2003)

A 25 percent improved medication adherence was observed in a study with patients using telehealth. (Cherry et. al 2003)

In delivering pharmaceutical care effectively to frail elderly patients through

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consistent and timely review, by promoting compliance and concordance with medication through staff training and through telehealth solutions, independence and well being in a homely setting will be supported, as will safety and risk reduction

This supports policy objectives and strategies, such as: Reshaping Care for Older People (2010) Live Well in Later Life, Edinburgh’s Joint Commissioning Plan (2012-2022) Integration of Health and Social Care Market Shaping Strategy(2013) Personalisation Agenda

to meet the challenge of increasing numbers of older people. Key objectives of the service are to:

Facilitate early discharge from hospital and prevent admission Maximise people’s independence to remain in the community for longer Supporting people to achieve better outcomes

Reduce carer stress.


The initial phase included a period of induction/familiarising for the pharmacist in relation to the new medicines policy (another Change Fund workstream in Edinburgh) and the range of systems, procedures and requirements (including Care Inspectorate reporting standards).

Engagement with key stakeholders also began in this initial phase, and included raising their awareness of the project and the benefits of the medication review service and to promote the availability of a pharmacist to conduct a medication review and act as a point of contact for advice and referral. It was essential to engage with all those services and carers who had a role to play in the patients care pathway. The key services included: reablement and home care; the Edinburgh IMPACT service (supporting people with long-term conditions and their carers) which aims to improve the quality of life for patients, give support to carers and to reduce preventable hospital admissions; intermediate care; and COMPASS (another of Edinburgh’s Change Fund initiatives) a ‘virtual ward’ service model which includes increased support from a Medicine of the Elderly consultant and specialist Medicine of the Elderly staff within the community. Links have also been made with independent sector care providers to ensure they are aware of service.

The target group for this service are people who receive prompting or administration of medicines as part of their package of care. These are identified as level 2 (requiring prompting of medication by a carer) or Level 3 (requiring administration of medication by a home care worker from original packs accompanied by the recording of the administration of this medication on a MAR (Medication Administration Record) which has been supplied by the patient’s Community Pharmacy).

The project pharmacist has used SPARRA scores to identify patients most at risk.

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High activity levels have been achieved. The level of awareness generated as well as the interest and support from homecare, reablement and other services provides a continual cohort of patients who would benefit and require an ad hoc medication review. This integrated team approach ensures the review of medication package includes input from both a social and clinical perspective and is delivered in a safe and effective manner.

The service is now able to be reactive and responsive to all colleagues. The anticipation is that this will grow further as there has been a dramatic rise in the number of colleagues from all teams referring for a timely solution and action.Level 3 medication patients have increased in number, and the number of issues raised, along with their complexity, is steadily increasing. This means that there is now a constant demand for an accessible, supportive and reactive point of contact which can offer a timely service with appropriate solutions.

The integrated approach and partnership working which has been inclusive of social and healthcare teams has improved communication and understanding of each sectors role. This has improved accessibility to rich information of patients and a combined approach to identifying needs for medication reviews and monitoring the benefits to the patient.

In addition to using SPARRA scores to identify patients most at risk, the project pharmacist and has participated in and contributed to the SPARRA working group, helping to improve its use as a real life tool and indicator to identify patients at risk of admission. The involvement and interaction with multi-disciplinary team which forms the SPARRA working group, has raised awareness of the medication review service for Level 2 and 3 patients, as well as creating referral pathways for GP’s and other community teams The use of the SPARRA tool has also allowed this project to align with the Scottish Government’s Polypharmacy Strategy, which is in its infancy of national implementation.


Further information can be sought through: Stefan McDonald, Project Pharmacist,

[email protected] Eleanor Cunningham (Evaluation lead)

[email protected].



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Preventative and

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Y







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YSpecialist clinical support for care homes



Enablers

Outcomes-focussed assessmentCo-productionTechnology/eHealth/Data SharingWorkforce Development/Skill Mix/Integrated WorkingOD and Improvement SupportInformation and EvaluationCommissioning and Integrated Resource Framework

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Name of Initiative Highlighted Home Care Overnight ServiceDate of Submission

Primary Contact Andy ShanksEmail [email protected] # 0131 553 8440



The Home Care Overnight Service provides support to older people aged 65+ in their own homes between 2200 and 0730. Each team consists of two workers on duty at any time, working in pairs. Each team makes around 20 visits per night and as such each visit is usually relatively short. Some individuals receive multiple visits per night and there is a mix of cases between long-term and short-term interventions. There are now six teams providing care throughout the city which prevent people with high care needs from being admitted to care homes or hospital.


The complexity of people with care needs has increased over recent years. The service means that people with high level needs can be supported at home with care delivered overnight. Previously this was only possible in a residential or hospital setting. Prior to the investment from the Change Fund there were two Overnight teams. The investment from the Change Fund allowed another three teams to be established. This has allowed people to move home from hospital, or remain at home, whereas previously a move away from home would be the only feasible outcome for meeting their needs. In some cases the requirement for care overnight was the only stumbling block to meaning someone could be cared for in their own home.


An element of risk was attached to expanding the service as there was little knowledge about unmet need. The feeling with senior managers was that requests for overnight care were not being made because the service was so limited in

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capacity. Previous experience was that when the second team was established the new capacity was filled very quickly. It was anticipated that as capacity became available, the type of care provision would change and more people would be able to stay at home. As expected, once established, capacity within the new teams was allocated quickly.


As mentioned above, once established the capacity in the teams was quickly used. This implies that more people were able to be supported at home than would previously have been the case. If the service had not been in place then there would have been no alternative to meet the care needs of people receiving the service other than to be admitted to hospital (in the short-term) or a care home (in the long-term).


Andy Shanks, Homecare and Re-ablement Manager [email protected]

Philip Brown, Evaluation Lead [email protected]



Preventative and

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Home

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Y Reablement & Rehabilitation Y




Y




Y Carer Support and Respite Y







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Y



YMedicine reconciliation and reviews



Y Carers as equal partners

Support for carers


YSpecialist clinical support for care homes



Enablers

Outcomes-focussed assessmentCo-productionTechnology/eHealth/Data SharingWorkforce Development/Skill Mix/Integrated WorkingOD and Improvement SupportInformation and EvaluationCommissioning and Integrated Resource Framework

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Name of Initiative Highlighted Care Homes Small Investment FundDate of Submission 27/09/13

Primary Contact Caroline ClarkEmail [email protected] # 0131 469 3220

Pathway: Hospital and Care Home(s)


A one-off investment fund was established to support innovation and improve outcomes for older people in care homes. The fund was open to all care homes in Edinburgh for small investments of up to £10k.


The fund aimed to support activities to enhance the quality of life for care home residents.


An application form and guidance was circulated to all care homes (independent and Council) in January 2013. A panel considered the applications made and funding was awarded to 21 care homes.


The successful projects can be grouped into the following themes: Reminiscence work – including a 1950s room, reminiscence ‘pop-ups’ (a pub,

cinema and 1950s room), football reminiscence project Gardens – applications to create more accessible, sensory, or music gardens Art, music and activities – including a wish tree and outings, a craft cafe,

dance and music therapy

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Technology – use of technology to support residents to achieve a wide range of outcomes

My Life Software – applications from 8 care homes, for a total of 14 digital reminiscence units

Projects are currently being implemented and will provide 6 monthly evaluation updates to demonstrate the impact on the outcomes for residents. Dementia mapping is also being used to evaluate the impact of 6 projects, covering a range of themes. The work will be written up to inform good practice across care homes in Edinburgh and to a wider audience.


Caroline Clark [email protected] Rene Rigby [email protected]



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Suitable and Access to range

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varied housing and housing support

of housing options

Enablers

Outcomes-focussed assessmentCo-production YTechnology/eHealth/Data Sharing YWorkforce Development/Skill Mix/Integrated Working YOD and Improvement SupportInformation and EvaluationCommissioning and Integrated Resource Framework

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Name of Initiative Highlighted My Home LifeDate of Submission 27/09/13

Primary Contact Rene RigbyEmail [email protected] # 07568335448

Pathway: Enablers


A Change Fund bid for 30 care home managers pan City of Edinburgh to participate in the My Home Life leadership support and community development was successful. M.H.L. course will last for fourteen months and Talking Points personal outcomes are being threaded through the programme. Some expected outcomes from this course, are:

developing managers into leaders promoting best and innovative practice through appreciative support and

transformative action care homes responsive and ready to meet future need improved quality of life for older people those living, dying, working in and

visiting care homes a perceived reduction in management burnout Care Home Community strands being established.


Development of leadership and management skills for care home managers.


Disseminated written information, regarding the opportunity to participate in MHL, in tandem this subject was raised via the Providers’ forum. Each manager was met with individually and given further relevant information. Having ascertained the numbers of people wishing to participate, a Change Fund bid was submitted. At this point also it was suggested that it would be an ideal opportunity to reinforce the Talking

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Points personal outcomes approach. This was agreed by the course leader Prof Belinda Dewar, and facilitators with experience in talking points were recruited to lead/ facilitate the MHL workshops. The programme commenced 15th May 2013 and will run for 14 months.


Very positive evaluations by all participantsExcellent attendancePeople are already making changes in their practice particularly in the way they engage with staff, families and residentsPeople are becoming more mindful of language e.g. - Changing the language can be very powerful eg protected mealtimes > supported mealtimes - ‘protected’ implies ‘keeping out’, supported implies caring.

People felt: Able to question without being judged Realisation that they don't have to be a fixer of all problems Great networking Space to reflect and really consider our practice Safe place to be challenged

The programme has been very positively received by all those involved although to date only anecdotal evidence from Professor Dewar, course facilitators is available at this juncture. All the participants have said how positive and helpful in their role as managers the MHL programme is.


Professor Belinda Dewar University of the West of Scotland



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Outcomes-focussed assessment YCo-production YTechnology/eHealth/Data SharingWorkforce Development/Skill Mix/Integrated Working YOD and Improvement Support YInformation and EvaluationCommissioning and Integrated Resource Framework

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Name of Initiative Highlighted Making it ClearDate of Submission 27/09/13

Primary Contact Jacqueline PentlandEmail [email protected] # 0131 474 0000

Pathway: Enablers


Making it CLEAR (Community Living, Enablement and Resilience) is a partnership with Queen Margaret University. The project aims to enable older people to live well within their communities by better understanding what supports them to remain resilient.


The evidence base to inform the allocation of the Change Fund was acknowledged to be weak in many areas, and a particular gap was identified in relation to the factors that build and maintain the resilience of older people in the community. Making it Clear was commissioned to build evidence in this area and also to apply the findings in a practical way.


The Making it CLEAR project aims to: learn how to create resilient communities for older people identify and measure the benefits associated with resilient communities conduct this as a participative project; creating real benefits whilst learning

how to effect change


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Deliverables to date include an integrative literature review which has informed the development of a tool to measure resilience. The tool is being robustly tested through working with older people in Edinburgh and will enable us, for the first time, to objectively measure the concept of resilience. Analysis of the data will now direct the next stages of the project.


Jacqueline Pentland [email protected]



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Outcomes-focussed assessment YCo-production YTechnology/eHealth/Data SharingWorkforce Development/Skill Mix/Integrated Working YOD and Improvement Support YInformation and Evaluation YCommissioning and Integrated Resource Framework

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change fund 2013/14 - mid-year review - web viewchange fund 2013/14 – mid-year review. ......

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