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MODELS OF INTERMEDIATE CARE

MODELS OF INTERMEDIATE CARE. Sandra Mackay, Planning Manager, North Lanarkshire Council. Integrated Day Services. Locality Planning Groups. Assessment & Rehabilitation Services. Building Staff Capacity. Assistive Technology. Locality Link Officers. Sheltered Housing. Carers Support.

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MODELS OF INTERMEDIATE CARE

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  1. MODELS OF INTERMEDIATE CARE Sandra Mackay, Planning Manager, North Lanarkshire Council

  2. Integrated Day Services Locality Planning Groups Assessment & Rehabilitation Services Building Staff Capacity Assistive Technology Locality Link Officers

  3. Sheltered Housing Carers Support Home Support Intermediate Care Respite Community Halls Community Hospitals Activity Programmes Care Homes Care Management Palliative Care Acute Hospital Services Continence Services Community Health Services Community Alarms Intensive Home Support Assistive Living Technology Aligned Home Support/Community Nursing Service Very Sheltered Housing Voluntary Organisations/ Support Locality Link Officers Early Supported Discharge/ Rapid Response Teams Community Pharmacy Mental Health Services Services for Older People

  4. Home Care Manager Senior Charge Nurse Day Hospital Integrated Service Co-ordinator JOINT ACCESS TO RESOURCES District Nurse Team Leader Senior Social Work Officer LPG’s Locality LinkOfficer Community Psychiatric Nurse Locality Planning Groups

  5. A&RS Assessment & Rehabilitation Services (APR 08 – MAR 09): • NUMBER OF SERVICE USERS ACCESSING SERVICE = 64 • AVERAGE LENGTH OF STAY = 31 DAYS • TEAM CONTACTS (WITHIN CARE HOME) = 699

  6. Improving Outcomes Mrs C • 86 years • poor short term memory • car accident – multiple injuries • admitted to care home for rehab • GP recommending Mrs C remain in care home due to increase in confusion

  7. IDS Integrated Day Services Previous Health and Social Care Day Provision Old Age Psychiatry/ Day Hospital Services Acute Health Service Day Hospital/ Services Existing Social Care Provision Community Resources

  8. Old Age Psychiatry Acute Day Hospital Social Work and Community Resources Integrated Day Services: New Model INTEGRATED DAY SERVICE

  9. Improving Outcomes Mrs W • 78 years • long standing delusional ideation re people being in her home • forgets to take medication • commenced integrated day care

  10. Service Outcomes Initial and annual review of integrated day service for older people using:- Talking Points (with service users and carers by variety of methods) 3rd person interviews Creative meetings – ‘My Perfect Day’ Integrated Team Monitoring and Assessment (ITMA) tool NES – Intermediate Care Capability Framework Above methodology to be rolled out to new integrated day service provision in 4 localities

  11. BSC Building Staff Capacity Joint development sessions for District Nurses & Community Psychiatric Nurses on ‘Outcomes in Practice: Developing a Common Understanding’ Very positive feedback

  12. LLO What a Locality Link Officer Does • Provides information about what's on in the local community • Helps people organise transport to community resources • Helps develop community groups • Keeps in touch with those who have poor social networks • Identifies gaps in community resources and fills them

  13. AT Assistive Technology Growth in Use during 2008/9

  14. Improving Outcomes Mrs G • 87 years • has severe dementia • clearly wishes to stay in own home • son anxious about mother’s activity through night and changes in behaviour

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