Community Division Western Isles Health Board Finella Morrison - Lead Nurse | Community Night Nursing Service | · Establish a night nurse post in the community to replace current multiple on-call nurses · Positive evaluation following a 3 month pilot · Prevents unnecessary admissions to hospital · Maintains patients at home overnight during periods of increased nursing care needs. · Most benefit will be to elderly patients who, if admitted, would risk becoming delayed discharges · Nurse liaises closely with OOH GP and SAS. Has attended with SAS in response to a 999 call and been able to put care in place thus preventing removal to A&E which would have resulted in admission. · Nurse responds to NHS24 contact · Nightly data collection in place and currently linked to the CCI unscheduled care project | · Prevents unnecessary emergency admissions · Liaises closely with day community nursing services to maintain nursing input and support to family carers. · Liaises with the hospital Patient Journey Facilitator to ensure overnight care is appropriate to settle patient back into home setting and prevent re-admission · Works closely with home care service to provide support, training etc as required. · | £130,000 |
Social Services Department of CnES John Edward | Mobile Overnight Support Service (MOSS) | - MOS S established about 4 years ago and now at capacity in Stornoway area.
- Maintain current service and continue roll-out to rural areas - Westside and Broadbay at present
- Provides night settling up till midnight.
- Visits clients during the night for toileting
- Overnight visits as required to monitor a client's safety
- Provides night respite for family carers
- Prevents admission to hospital by the provision of the service and the support to the carers.
- Works closely with the community nursing, homecare and social work services and also with the Community Night Nurse (see above)
| - Prevents unnecessary admission to hospital
- Assists with discharge to home
- Provides resource for OOH care and monitoring
| £120,000 |
Western Isles Hospital Division of Western Isles health Board Michael Hutchieson | Patient Journey Facilitator (PJF) | - Establish a nursing post within the acute hospital to focus on discharge planning
- Pilot post of Discharge Co-ordinator showed improved journey time.
- Daily focus on emergency admissions to identify any deemed to be unnecessary and reports to Community Division. Lead Nurse will liaise GP/SAS to discuss and ensure awareness of all services e.g.Community Night Nurse - in place to prevent recourse to admission.
- Follows emergency and scheduled admissions to ensure discharge plans are in place
- Maintains contact with staff to identify any potential delays as soon as possible
- Will liaise with the Community social and nursing services to ensure services are in place for discharge.
- Will monitor the use of SSA and Care plans to ensure these are completed correctly and follow the patient.
| - Focus on all admissions will reduce delays in the system
- Focus on delays will speed up the patient journey by improving communication between services.
- This focused attention will greatly improve the assessment process
- Increased focus on discharge planning from admission for emergencies and pre-admission for scheduled admissions
- Monitoring emergency admissions will help to identify unnecessary admissions and enable education of all community and Primary care service providers
- Improved liaison between hospital and community will ensure resources are available timeously in preparation for planned discharge.
| £33,000 |