Within Each of the New Localities, the Edinburgh Health and Social Care Partnership (Also

Background:

Within each of the new localities, the Edinburgh Health and Social Care Partnership (also known as the Integrated Joint Board or IJB) is developing ‘Locality Hubs’ which will bring community staff from across sectors and from the widest range of disciplines to take on two core roles:

• Reducing the time that older people need to remain within acute hospital environments; and
• Reducing the numbers of people being admitted to hospital, where there would be appropriate community based supports available.

Achieving these outcomes is, of course, a complex proposal, but one which holds at its core two very real and tangible activities:

• Improving quality of life, wellbeing and health for Edinburgh’s older citizens; and
• Improving the way that the whole workforce can come together to tackle the very real challenges of unnecessary admissions and delays to discharges for older people.

These Locality Hubs will recreate the environment of the Cottage Hospital within the City, in that staff will be able to come together to troubleshoot cases, ensure that key actions are taken collectively and maintain clear lines of communication to ensure coherent care coordination.

LOOPs Hospital Discharge Project:

The LOOPs Hospital Discharge builds upon the successes and infrastructure of the LOOPs Community Projects. These include the LOOPs Phoneline and a range of on-the-ground Community Navigation projects, whose focus is on improving uptake and information about existing Third Sector preventative health and social activities.

We believe that the work will be a first within Scotland, in that it builds a single coherent interface for the Third Sector into the hospital environment, with the support of both Health and Social Care colleagues, and which will see the delivery of an end-to-end service to improve discharge efficiency and community supports to older people.

The project works on a number of levels and with a range of people but starts by placing Third Sector staff in key positions – both within the Locality Hub and within the acute hospital Discharge Hub.

These staff will be available to take referrals at morning huddles and multidisciplinary team meeting throughout the day with the aim of ensuring that consistent, managed referrals are made to existing Third Sector services and activities. By so doing, our team will build a social bridge across the discharge transition that will provide support to avoid future admissions by ensuring timely support is delivered within the community.

How it works:

Within each of the Locality Hubs and the acute hospital setting, our staff will be available to take referrals directlyfrom statutory and Third Sector colleagues and will begin to process those referrals directly within the hospital. This will save time for your own teams as relationships and knowledge of these services is key to a successful referral.

Hospital based Third Sector Liaison Workers will begin to provide support and advice to service users within the hospital about improving support within the community on returning home. Community based Discharge Support Development staff will work closely with Hospital based staff to ensure that referrals and support are being developed in an expedited manner.

Expedited Referral Pathways:

Staff within the Locality Hubs will develop a number of expedited local referral pathways to ensure that there are the fewest delays possible within referrals and that patients are supported from the time they leave the hospital.

These referral pathways will include:

• Falls, Reablement and Exercise.
• Individual Long Term Conditions (e.g. COPD), Wellness and Self-Management.
• Day Care services and lunch clubs.
• In-home community based service delivery (e.g. Library Link).
• Social Reablement (e.g. Community Connecting).
• Befriending and Social Support.
• Advice and Information (e.g. benefits, pensions and housing support).
• Legal Information (e.g. Power of Attorney).
• Strengthening Local Social Supports.

Hospital 2 Home:

Where an older person has limited family or carer support or where people have been taken to the hospital in a crisis, and may have remained for some weeks it can become quite daunting to return home: perishables may have spoilt, the home might be very cold or people might require some support to make the home more comfortable.

With permission, our Hospital 2 Home service will provide volunteers to support some of the more practical elements of returning home:

• A volunteer will visit with the patient in the hospital to find out what might need to be done to make the home more comfortable: this could include purchasing basic food and milk, airing out the house, pushing around the vacuum cleaner.
• A Community Transport provider will support the person through the journey home.
• A volunteer will meet the patient upon their return and spend time helping them to setting in and, where suitable, providing information and advice about preventative health and social activities.

During the subsequent weeks, services aligned to the project and arranged through the Locality Hub will begin the process of ensuring a more holistic community response is engaged through befriending, gardening, friendship groups, lunch clubs and Day Services etc.

Peer Support:

Throughout the project we will be working to identify new ways to develop peer support for people who have found themselves admitted to hospital and/or who may have become subject to a discharge delay.

The precise details of this are yet to be clarified but we believe that there are ways to support people within the hospital to develop local networks which extend back to the community.

Peer support has been shown, time and again, to be more accessible to people who may feel less confident speaking about health and wellbeing challenges – particularly older men. We will be consulting with Third Sector providers and staff within the Statutory Sector, as well as local older people about how this element of the project could be developed to best effect.

In-patient Day Pass Arrangements:

We are currently exploring the possibility of working with local Third Sector Day Care providers to provide time outside the hospital environment. Day Care services typically provide up to four hours of support, within the community and with other older people. Throughout this time, activities are carried out including low impact exercise, meals, games, etc.

By ensuring that people are able to get out of the hospital environment, we expect that we can reduce the impact of a stay in hospital – which can often lead to increased frailty and a loss of independence.

Why the Third Sector:

During a recent mapping exercise, it was identified that there are in the range of 2500 dedicated activities for older people delivered each week. These are carried out by around 450 organisations who are locally based and community focused.

Often these are delivered just by one or two volunteers with very little finance support[i] butacross Edinburgh, the Third Sector employs 15,000[ii] hard working individuals and has a turnover of £2.2 billions[iii].

At the same time, it is clear that there are fewer and more frugally allocated Statutory Services and of these services we need to be sure that they are allocated to those with the highest levels of need. The Christie Commission Report of 2011.[iv]

Recent National Public Health strategy (i.e. Reshaping Care for Older People[v]) and local joint commissioning plans (e.g. Live Well in Later Life: Edinburgh’s Joint Commissioning Plan for Older People[vi]) have moved perception of the role of the Third Sector from that of delivering ‘nice-to-have’ ancillary services to the understanding that without the core services provided by the Third Sector that the system would grind to a halt.

This project will ensure that this complex arrangement of large, small, and tiny organisations is always available to everyone to Edinburgh’s older citizens at that crucial time of need.

Engagement:

The LOOPs Hospital Discharge Support Project will be delivered by a partnership of Third Sector providers. This collaboration will deliver the work within the acute hospital and Locality Hub settings. These are:

• Edinburgh Voluntary Organisations’ Council (EVOC),
• Eric Liddell Centre (ELC),
• Health in Mind, and
• Libertus Services.

It is likely that additional providers will be recruited to deliver other pieces of work – for example, Community Transport operators will be best placed to support journey’s home from hospital – but we want to see this project as a ‘One Sector, One System’ response to this key challenge.

To this end we have carried out a number of engagement events with the Third Sector but will be carrying out a number more with:

• National Providers – e.g. Chest Heart and Stroke, Parkinson’s UK, The Alliance.
• Statutory Sector Workforce – e.g. Sector Teams, In-service training and awareness raising.
• Local Providers: within each Locality.
• At LOOPs Network Meetings – in each Locality.

The first of these events will be to introduce the project to National providers, many of whom will focus on a single condition.

Details of that event, and future events will be available on the EVOC website at in the LOOPs section, under Partnership.

Local Opportunities for Older People – LOOPs:

Within the Day Care Services Commissioning Plan (2012-17), it was identified that current usage for Day Care within the city was unsustainable and that the service of a Day Care facility should be reserved for those in the highest levels of need.

In order to facilitate this change, three additional services were designed to support older people to reengage with the community and to improve physical and mental health and wellbeing:

• Community Connecting: provides 16-weeks volunteer support to reengage with activities within the community and to begin to identify goals for further health and wellbeing interventions – e.g. falls prevention.
• Be-Able: provides group Reablement activities focussed around falls prevention and reducing levels of cognitive impairment amongst people with the early stages of dementia.
• Local Opportunities for Older People: aims to rebuild community infrastructure to ensure that older people, particularly those who may have become socially isolated, are able to connect to existing Third Sector activities, to improve choice and promote early intervention.

LOOPS Community Projects:

The LOOPs Community Projects focus on reducing social isolation and improving access to local services – there are 5 projects delivered across the city as follows:

• The citywide LOOPs Phonelineprovides a resource to ensure that older people, families and friends and staff across the system are able to access clear and easy to understand information about Third Sector activities. If you would like to find out more, please give them a call on 0131 603 8311
• Within the North East and South West there are Community Navigator projects. These work with older people on-the-ground by providing a regular presence in the places that people are likely to be – shopping centres, libraries, supermarkets. At these sites information and advice can be sought. These community navigator projects are being developed to be replicated in the North West and South East in the coming months.

North East and South West Community Navigator projects are currently delivered by:

• North East: Pilmeny Development Project.
• South West: Health in Mind.

LOOPs Networks:

In order that staff are better able to support one another across sectors and services. EVOC and Pilmeny Development Project currently deliver this work which provides opportunities to:

• Get to know colleagues – across sectors.
• Establish partnership working.
• Learn about key strategies and new services.
• Consult with staff and service users within the community.

Edinburgh Voluntary Organisations’ Council is a company limited by guarantee no. SC173582 and is a registered Scottish charity no. SC009944. Registered Office: 14 Ashley Place, Edinburgh, EH6 5PX

[i] EVOC RedBook – The Online directory to find organisations, and their services across Edinburgh, Edinburgh Voluntary Organisations’ Council, Edinburgh.

[ii] Edinburgh by Numbers, City of Edinburgh Council, Edinburgh (2014).

[iii] Office of the Scottish Charity Regulator, Dundee, (2015)

[iv] Report on the Future Delivery of Public Services, Chaired by Christie, C., Scottish Government, (2011).

[v] Reshaping Care for Older People: A Programme for Change 2011-21, Joint Improvement Team, Edinburgh, (2011).

[vi] Live Well in Later Life: Edinburgh’s Commissioning Plan for Older People 2012-22, City of Edinburgh Council et al. (2012)