INITIATIVE - brief description only | National Priorities and Objectives | Spend 06/07 | Lead Responsibility | Who will Benefit and How | Impact of These Measures | Data Collected | Key risks | |
1. Capacity review of long term care options locally including residential care, supported accommodation (sheltered and very sheltered housing) and Care at Home. Specifically, of needs for long term care provision in the north isles following report completed on Isleshavn care centre in Yell. | B, C, E, H | £35k | Discharge Planning Group | Long term - projected increasing numbers of older people who need support will be maintained at home or in other community settings locally. | Low/zero delayed discharge level maintained. Number of emergency admissions reduced | No of people on waiting list for residential care. Levels of need (IoRN) No of people receiving augmented care packages in the community | Capacity of existing resources - unable to meet increasing levels of need. Increasing pressure on resources both financial and human. | |
2. Continuing development of the integrated continence service to help avoid hospital admission. Service review scheduled for November 2006. | E, G, I | £38K | CHP Lead Nurse | Enhanced continence service for patients at home preventing hospital or residential care admission | Low/zero delayed discharge level maintained. Number of emergency admissions reduced | No of patients supported | Capacity of service dependent on one specialist post. | |
3. Review of discharge protocols following changes to admission and discharge policies for residential care and Interim Placement Unit, made in 2005/06 | B, C, D, F, H, I | WER | Discharge Planning Group | Improved patient experience on discharge from hospital. Provision of better information for patients and their carers at the point of discharge. | Low/Zero delayed discharge numbers maintained | No. of transfers offered and performance against 10/98 targets. No. of discharge exception reports and outcomes. | Lack of political support locally for interim placements against individual's stated preference or choice. Capacity issues and distance from Scottish mainland making placements in neighbouring LA areas unacceptable. Distress for the patient and their family when they are unable to return home or to their locality. | |
4. Dementia Services Redesign Project. This project includes a review of the specialist resources available from Viewforth House in Lerwick. Part of reprovisioning for long term care. See also 1. above. | B, C, D, E, F, G, H | £35k | Nursing Development Officer reporting to the Discharge Planning Group | Expect people with dementia to benefit from more efficient, effective service provision. Long term: more appropriate facilities available on Shetland for this care group. | Low/Zero delayed discharge numbers maintained | No of people with a diagnosis of dementia. Aggregate data from CareNap D No of people with dementia in specialist care settings | Lack of staff time due to commitments on other development projects. Lack of funding to develop new facilities. | |
5. Implement recommendations from day care review. | B, C, D, E, F, G, H, I | WER | Older People's Management Team | Expect enhanced day care provision to increasingly support people with higher dependency needs enabling them to continue to live in their own homes. | Increasing contribution to meeting quarterly targets for low/zero delayed discharges. | Current use of day care services and levels of need. Waiting lists for day care services | Lack of political support for changes to day care criteria. Lack of funds to implement changes. Limited activity in voluntary sector locally to meet low level needs and the aspirations of the community. | |
| 6. Continuing service developments at Montfield including review of day hospital service for younger adults with physical disabilities to better target resources | B, C, D, F, H, I | TBA | Director of Clinical Services | Improved services for patients resulting in early discharge and reducing re-admission rates. | Low/zero delayed discharge numbers maintained | Admissions and discharges statistics. Waiting list | Opposition to any change in day hospital provision Lack of additional resources for new service developments. |
| 7. Review of needs for specialist care services for younger adults with physical disabilities (see also 6 above) | B, C, D, E, F, H | £14k | Physical Disability & Sensory Impairment Management Team | More appropriate service provision maintaining people at home or in other community settings. | Low/Zero delayed discharge numbers maintained | Admission and discharge statistics. Waiting Lists. Unmet need. | Sustainability of preferred models e.g. specialist supported accommodation. Lack of staff time to undertake review. |
| 8. Review the role of Montfield Hospital regarding palliative care admissions. | F, J | WER | Shetland Task Force on Cancer and Palliative Care | People in the last stages of life better supported and where possible supported to return home. | Reduce re-admission rates | Outcomes for palliative care cases. Numbers supported at home. | Availability of sufficient resources to maintain flexible, responsive services both in the hospital and the community. |
| 9. Review of Continuing Care Criteria and further review of Interim Placement Unit (IPU) in this context. The IPU was established in January 2005 to provide up to 10 places for patients ready for discharge who no longer need acute health care. | B, C, D, F, H, I | £30k | NHS | Patients discharged to the IPU are cared for in a setting that will maximise their independence until substantive discharge arrangements are implemented. The review of continuing care criteria will give clarity regarding the continuing need for long term hospital care and the role of the IPU. | Low/zero delayed discharge numbers maintained | Turnover in IPU Budget provision and spend | Sustainability of the IPU in future years. Lack of sufficient community based long term care. |
| 10. Implementation of action plan from agreed multi-agency Disability Strategy | B, C, D, E, F, G, H, I | WER | Joint Future Joint Management Team | People with disabilities where specialist disability services and therapies are an important part of discharge plans better supported on discharge. | Low/zero delayed discharge numbers. Reduction in re-admission rates | Admission and discharges statistics. Waiting lists. | Sustainability. Need to focus resources on areas of greatest need in an area where very high levels of service have been widely available. |
| 11. Pilot generic support worker and contracted relief worker proposals linked to the locality based Care at Home Service. | B, C, D, E, F, G, H, I | TBA | Community Health Partnership Management Team | Improved service for up to 250 people receiving personal and/or nursing care in the community. | Low/zero delayed discharge numbers maintained. Reduction in admissions to hospital and residential care. | No of people receiving care by number of hours received. Locality based information on care provision. | Capacity issues of locality management model particularly in the rural areas. Staff shortages in some areas. ICT capacity and poor electronic links to care centres. |
| 12. Implementation of devolved responsibilities for care services to people at home supported by SSA procedures and training programme including staff from independent sector providers. | B, C, D, E, F, G, H, I | WER | Single Shared Assessment & Care Management Team | People waiting for discharge from hospital or needing changes in levels of care will have their needs met more quickly. | Earlier discharge from hospital. Reduction in admissions to hospital and residential care. | No of SSA completed by agency, role and locality. Budget allocation and spend by locality | Delayed implementation of shared ICT systems to facilitate information sharing. Staff commitment to new ways of working. |
| 13. Review of Accident and Emergency (A&E) procedures with a view to reducing unplanned admissions to hospital. | E, F | WER | Discharge Planning Group | People receiving assessment/treatment in A & E supported to go home rather than admitted to hospital | Reduction in hospital admissions | No. of emergency admissions. Outcomes for patients in A & E. | Staff commitment to new ways of working. Lack of staff time to undertake the review. |
| 14. Review the outcomes from the Pilot Falls group run by OT and Physio services to inform future service developments | E | WER | Clinical Falls Prevention Group | People at risk of falling, supported to reduce risk | Reduction in hospital admissions | No. of emergency admissions due to falls. | Lack of funding in both OT and Physio services to develop pilot further. Transport difficulties. |