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.