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Bristols Promoting Independence Team

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What are we aiming to do? Reduce the number of older people experiencing crises ... The windows are ill fitting and stuffed with rags to prevent draughts ... – PowerPoint PPT presentation

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Title: Bristols Promoting Independence Team


1
Bristols Promoting Independence Team
  • Sue Cheasley, Team Manager
  • Maya Bimson, Transformation Programme Manager

2
What are we aiming to do?
  • Reduce the number of older people experiencing
    crises
  • Increase the engagement of local communities in
    supporting older people
  • Explore the use of AT to help maintain
    independence
  • Promote integration across health and social
    services

3
How?
  • Piloting 2 Promoting Independence Teams in two
    areas of Bristol
  • Multi-disciplinary, including mental health
  • Both areas have have high levels of deprivation,
    one has large BME population
  • Pump priming money for local voluntary
    organisations

4
Who are in the teams?
  • Community Nurse for Older People
  • Assessment and Review Coordinator
  • Community Mental Health Nurse
  • Community Development Worker
  • Part-time manager across 2 teams

5
What will the teams do?
  • Case Finding
  • - Ambulance Trust
  • - AE
  • - GPs
  • - Care Direct
  • Take referrals from
  • - professionals inc vol sector
  • - older people and their carers

6
Eligibility criteria
  • The teams will provide a service for vulnerable
    older people, aged 65 or over, who may not be
    receiving a community based health or social care
    service. They must have non-acute health and
    social care needs that do not require a rapid
    response.
  •  

7
What factors might prompt a referral?
  • Memory problems/ dementia
  • Mental health problems depression
  • Falls
  • Frail Elderly
  • More than 4 medications
  • Social isolation
  • Bereavement
  • Alcohol and other dependency issues
  • Financial worries

8
Case Management
  • A screening telephone call
  • An assessment visit
  • Agreeing priorities with the user
  • Developing an action plan
  • Directly arranging the provision of services if
    not eligible under FACS

9
Case Management
  • Making appropriate referrals
  • Actively monitoring the progress of any referrals
    and service delivery arrangements with a focus on
    making things happen
  • 6 month review

10
Case Study
  • Flo approached one of the Teams workers at lunch
    club
  • She wanted to discuss accessing the community bus
    to enable her to use the local shops for fresh
    vegetables as she is diabetic
  • During a general conversation she mentioned that
    she was managing with difficulty

11
  • Flo was living in a council house where she had
    lived for 60 years
  • She was about to have her electricity cut off
  • She had fallen twice in the garden due to
    uneven paths and slipped off the last stair in
    the house and hit her head in the last few days
  • She lived in one very cluttered room downstairs.
    She sleeps in this room with a gas fire sometimes
    left on all night

12
  • She accessed her toilet upstairs on her hands and
    knees
  • Her kitchen is in a very bad state of disrepair
  • The windows are ill fitting and stuffed with
    rags to prevent draughts
  • All laundry is done by hand, dried in bathroom
    and then aired on gas fire
  • During the winter Flo does not change her
    bedding as she is unable to wash and dry it.

13
Actions Taken
  • Falls Screening Tool identified 4 triggers which
    led to full falls assessment
  • Fast track referral to Independent Living Service
    led to hand rails being installed within 3 weeks
  • The teams community nurse sorted her medication
    problems
  • Energy payment scheme set up and Flo added to
    vulnerable person list

14
  • Housing Department contacted and surveyors visit
    led to Flo being offered central heating, repairs
    to path, new kitchen and new windows
  • Helped to use the Community Bus to access shops
  • Laundry services explored
  • Benefits checked for full entitlement
  • Eye Hospital visits for cataract
  • Dentist visit set up her first for 60 years!
  • Option of sheltered housing explored

15
Evaluation of the project
  • Both qualitative and quantitative targets
    established and data collected on Statistical
    Package for Social Sciences (SPSS)
  • Continual performance management to ensure
    targets are met
  • Overall evaluation by the University of West of
    England

16
Sustaining the Change
  • Using the evaluation to disinvest and re-invest
  • Using the pilot to build capacity in the
    independent sector
  • Using the experience to reconfigure existing
    health and social services teams

17
Two thirds of hospital inpatients are older
people and older people make up the largest
single users of health and social care services
so if we get it right for older people we are
likely to be getting it right for all.
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