Health and Social Care

NHS Forth Valley are working in partnership with Falkirk Council to test new ways to support people to live well at home in Bo’ness .

Phase 1 of the project initially looked at patients over the age of 85 with dementia and or multiple health related problems. It was noted that while most people in this position seemed to be relatively resilient with a good support network, there was a high incidence of Emergency Department (ED) attendance normally by ambulance.

Over an 18 month period 50 patients visited the ED 188 times.  We believe that at least 45% of these visits could have been dealt with at home if an alternative was available.  People told us that they called 999 as they did not know what else to do.

Phase 2 provided 200 people over 75 years (Scottish Patients at Risk of Readmission and Admission risk 40-60%) with a new package of support.  Firstly we gave them ‘Your Plan’ – an informal anticipatory care plan owned by the individual and developed with their family or carer.  This helps them plan for what they need to help them live well and what they should do if their needs increase. They are encouraged to consent to share this with health and social care staff.  Secondly we established ‘ALFY‘ – Advice Line For You – a nurse led telephone line which is available 24 hours a day.

ALFY doesn’t replace 999 or NHS24, and will redirect people if appropriate.  ALFY nurses who deal with the calls can offer a range of services:

• advice and reassurance
• a district nurse visit day or night
• an appointment at the Frailty Rapid Access Clinic
• signposting to social care or locality based services.

The service-user and their family are then invited to an education session to help them understand how best these options can help them.  Early responses have been promising with a full spectrum of calls and issues.

Phase 3 will see the service opened up in late March 2015 to everyone over 65 years old in Bo’ness, with local publicity to raise awareness.  We will then monitor potential impact on ED attendance and analyse call type and volume.

For more information please visit nhsforthvalley.com/ALFY where you can see three short video clips developed for the public to explain our new services. Alternatively please email Jann Gardner or call her on 01324 566720.