Delivering Better Outcomes –
Helping Older People to Help
Themselves
Tony Homer – Associate, Joint Improvement Team
Outcomes approach to community care
Outcomes Framework
Community care users
feeling safe
Users and carers satisfied
with their involvement in the
design of care package
Users satisfied with
opportunities for social
interaction
Shift in balance of care
from institutional to ‘home
based’ care
People 65+ with intensive
needs receiving care at
home
People 65+ receiving
personal care at home
Patients waiting in short stay
settings, or for more than 6
weeks elsewhere for discharge
to appropriate setting
Experience
Balance
of Care
People waiting longer than
target for assessment
Access
Outcomes
Framework
Emergency bed days in
acute specialties for
people 65+
People 65+ admitted as
an emergency twice or
more to acute specialties
People 65+ admitted
twice or more as an
emergency who have not
had an assessment
Risk of
Admission
People waiting longer than
target time for service
Carers
Quality
Assessment
User assessments completed to
national standard
Carers assessments completed
to national standard
Care plans reviewed within
agreed timescale
carers who feel supported
and capable to continue in
their role as carer
Outcomes approach to community care
Talking Points– core concepts
Understand outcomes as the impact or end result of
service(s) on a person’s life

The user or carer is involved in identifying desired
outcomes = setting goals in partnership with services


Partnership is key – users, carers, services, other
community resources – to delivering outcomes
Service user defined outcomes
Quality of life
Process
Change
Feeling safe
Listened to
Improved
confidence
Having things to do
Having a say
Seeing people
Respect
As well as can be
Responded to
Life as want (including
where you live)
Reliability
Improved skills
Improved mobility
Reduced symptoms
Carer defined outcomes
Quality of
Quality of life
life for cared of carer
for person
Coping with
caring
Process
Quality of life
for cared for
person
Choices in
caring including
limits
Feeling
informed/skilled/
equipped
Satisfaction in
caring
Partnership with
services
Valued/respected
Having a say in
services
Responsive to
changing needs
Meaningful
relationship with
practitioners
Accessible and
available and free
at the point of
need
Health and
wellbeing
A life of their
own
Positive
relationship
with person
cared for
Freedom from
financial
hardship
Grappling with the Service Change
Agenda
Cross-cutting policy priorities
> Personalisation
> Self Directed Support
> Telehealthcare
> Safety
> Information systems
> Service integration
Service Clusters
> Communities and informal networks
> Long term conditions
> Crisis care and interim support
> Housing and care options
Communities and informal care
> Supporting informal carers and volunteer networks
> Community capacity building
By:
> Better understanding the size, profile and needs of the
informal carer population
> Taking a non specialist perspective on what resources look
like – not overlooking universal public services
> Involving all sections of the community so that they feel
included and recognising that they have a contribution to
make
> Investing in the potential of the current community
Communities and informal care – South
Ayrshire
> Community development approach adopted across
regeneration, health and children’s services. Now also
incorporating Older People’s services
> Model based upon Asset Based Communities approach
> Focussing upon Girvan, a small costal town/hinterland with
regeneration funding and a new community hospital
> Care home re-provisioning with ECH being planned
> GIRFEC strategy included in developing agenda for
change – recognising everyone’s place in the community
Long Term Conditions
> Long term care collaborative
> Supporting better self care
> Shifting investment upstream into anticipatory and
preventative care
> Telehealthcare
> Using a re-ablement approach to re-skill and re-motivate
users rather then create dependency
A Planned Approach to Patients at High
Risk of Re-admission to Hospital –
Ayrshire & Arran
>
Use of SPARRA data to predict highest risk patients
>
Quarterly review of highest risk patients
>
Encourage use of self-management plans – GPs and DNTs
>
Review of all emergency admissions – A&E and Acute
>
Notification to NHS 24 and ADOC
>
Consideration of pulmonary rehabilitation
Crisis care and interim support
> Avoiding unplanned hospital admissions and readmissions
> Avoiding delayed hospital discharges
By:
> Appropriate rapid response
> 24/7 cover
> Intermediate care in a variety of settings
> Telehealthcare
> Respite support for carers
Crisis Care – Community based
intermediate care service - Orkney
Accommodation and care options
> Demographic impacts and housing
> Housing quality and accessibility
> Owner occupation and the social rented sector
> Care Homes
Aspects of the way forward:
> Investment in normal housing
> Practical services to support householders
> The challenge of cross-tenure initiatives
> Specialist housing
> New roles for care homes
Accommodation and care options –
Scottish Borders
>
>
>
>
>
>
Small rural town with dispersed hinterland population
Long term care home for people with degenerative conditions
Move to tenanted flats with onsite care and support in community
Re-ablement and re-skilling approach – reduced dependency
Social, activity and community engagement support
Shift involved access to state benefits – managing their own
money
> Gradual introduction of ILF applications/funding and shift of
purchasing control to users
> Adjustments to core provider budget and use of PAs
Things to remember
What would help us to help ourselves?
> Easy access to good information
> Choice - real options that address your own circumstances
> Control over deciding upon your preferred package /
pathway
> Self managed or actively involved in service
planning/delivery decisions
> Able to decide what opportunities and potential risks are
okay for you
> Within a supportive process that is driven by what works
for you