Health and Social Care Integration

Living Well in Communities

December 2, 2015 by No Comments

This blog post takes a closer look at Living Well in Communities, a new portfolio of improvement work which aims to help people to live well in their communities.

The portfolio

Living Well in Communities is a collaboration between Healthcare Improvement Scotland, the Joint Improvement Team and the Quality and Efficiency Support Team, which aims to support people to spend more time living at home or in a homely setting.

It will involve a broad range of stakeholders across health and social care, including health and social care partnerships, the housing sector, third sector organisations and private sector social care providers.

The portfolio has its origins in a speech made by Alex Neil, the former Cabinet Secretary for Health, Wellbeing and Sport, in November 2014, in which he declared an ambition “to give back at least 200,000 days to individuals, families and communities” that would otherwise be spent in hospital. This goal is to be achieved by December 2017.

Workstreams

Our improvement work will focus on the following areas, which have been identified as areas in which the pace and scale of improvement can be increased with the provision of additional improvement support:

  • frailty pathways and falls management and prevention
  • anticipatory care planning
  • improving links between the housing sector, health and social care
  • elements of delayed discharge, and
  • pathways for high-resource users of health and social care services.

The work will draw on testing from related programmes, and will use a variety of approaches to capture and share knowledge to increase the pace at which the learning from the project is applied in practice, including knowledge management tools and techniques and social media.

It is also particularly important for us to develop robust measures which will demonstrate the impact of the project’s improvement activities: there are existing programmes which also aim to help people to spend more time living well in a community setting and we need to be able to demonstrate the specific contribution of Living Well in Communities’ improvement programmes to shared outcomes.

Recent work

Living Well in Later Life and Living Well with Frailty

On 26 and 27 October 2015 we held two linked events, which explored how to support older people to live independently and respond to the complexities of frailty. The plenary sessions and diverse workshops shared good practice in care for older people and people living with frailty, and the events also offered delegates the opportunity to connect with and learn from others.

Some sessions were streamed live, and there was strong engagement on social media, with delegates making pledges on Twitter on how they plan to improve outcomes for older people and those living with frailty. Videos and other resources from the events are now available on the QI Hub website.

Glasgow Health and Social Care Partnership deep dive

Living Well in Communities recently co-produced a deep dive session with Glasgow City Health and Social Care Partnership to explore data on how people in Glasgow use health and social care services.

Much of the discussion focused on high resource individuals (HRIs). Key points included the need to  identify those HRIs that could be offered a meaningful alternative to acute provision (to target the individuals on whom improvement activity can have an impact), the need to distinguish between HRIs and frequent users of services and whether individuals who are HRIs for healthcare move on to become social care HRIs the following year.

Participants questioned whether acute admissions increase for people who are in close proximity to a hospital. It was also observed that risk aversion can prevent pathways from being followed in all situations, and that targets have an influence on decision-making.

Living Well in Communities will work with the partnership and the Local Intelligence Support Team (Information Services Division) to better understand these areas and explore opportunities for testing improvement work.

Learning from NHS Lanarkshire

The team also recently visited Monklands hospital in Lanarkshire to learn more about their pathways for frail, elderly people and NHS Lanarkshire’s Hospital at Home service. It was interesting to hear about how staff plan for discharge from the outset, and the innovative way in which they are providing some secondary care services in a home setting.

Next steps

The team will co-produce a deep dive session with Argyll and Bute Health and Social Care Partnership in December directed by their local priorities.

We are also co-hosting an event with Fife Health and Social Care Partnership in December to agree on the best method for identifying people at risk of frailty in the community.

To find out more about the project you can follow us on Twitter, or email the team at hcis.livingwell@nhs.net.


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