Smart Care The Lanarkshire Community Falls Pathway

Transcription

1 Smart Care The Lanarkshire Community Falls Pathway Karen Black, NHS Lanarkshire, Adult Community Physiotherapy Lead

2 What is Smart Care What does it aim to do NHSL Community Falls Pathway Register Next steps

3 A Smart(Care!) Collaboration 31 partners across Europe 10 Euro regions Best use of technology Coordinating activity Evidencing practice Scotland : First Wave Sharing knowledge

4 Smartcare in Scotland aims.. to improve the health, care and wellbeing of 10,000 people aged 50+ within Ayrshire and Clyde Valley, by enabling a better coordinated and more effective approach to falls prevention and management focusing on the role that ICT services and applications can play in supporting integrated care

5 SmartCare in Scotland Scottish Centre for Telehealth and Telecare (SCTT)/NHS 24 has national responsibility Smart Care area: 20% population ( 1.1m) 7 local authorities 3 Health Boards 3 rd Sector and Independent providers Target: 10,000 people at risk of falls

6 Lanarkshire Falls Pathway

7 Current pathway Pt. who has Fallen or is at RISK of Falling Referrers District Nurse Alert Alarm GP A&E Social work Self/family Clinics Wards NHS24 Other health staff DesOnaOons Falls Clinic Community teams (e.g. CARS/ICST) Physiotherapy (PT) clinics Community PT Social work : Community OccupaOonal Therapists Falls Team

8 Issues with current pathway Duplication of referrals Multiple registration/databases Inadequate admin support Geographical differences Inconsistent processes

9 Proposed pathway Referrers DesOnaOons District Nurse Falls Clinic Pt. who has Fallen or is at RISK of Falling Alert Alarm GP A&E Social work Self/family Clinics Wards NHS24 Other health staff Register Ini%al screening/ telephone triage Community teams (e.g. CARS/ICST) Physiotherapy (PT) clinics Community PT Social work : Community OccupaOonal Therapists Falls screener intervenoons offered which will support on- going self- management

10 NHSL Community Falls Register Pt who has fallen or is at risk of falling at home Seen by health or SW staff in the community Interventions as per normal processes LEVEL 1 Screening completed Consent obtained to share information with other agencies / Falls register, provide leaflet If required refer immediately / advise contact with GP

11 NHSL Community Falls Pathway continued General advice and info provided as per Falls guidance including Falls prevention leaflet Progress to Level 2 multi factorial assessment if indicated by Level 1 screening and it s within your scope or request Level 2 via register Send to Falls Register Team via secure or MiDIS (multi disciplinary information system)

12 Community Falls Pathway continued If consent recorded admin will add to register and check for any previous registrations/care manager or if Pt. Is on the case load of Health or SW staff. If known inform appropriate staff If Level 2/3 required sign post to relevant team for completion If information only indicated information pack will be sent out Future Plan Level 2 Assessment outcome added to register

13 Name: D.O.B./ CHI: Address: Telephone: GP Name/ Practice: GP telephone number: LEVEL 1 FALLS SCREENING It is important to identify people who would benefit from further assessment after falling, or those who are at risk of falling. Complete the following level 1 falls screening tool and send to the falls registry at the address below. * Please note that this is not a direct referral to the falls specialist service or falls medical clinic. BASIC SCREENING QUESTIONS 1. Have you fallen more than once in the last 6 months (NOT the result of simple accidental slips/ trips)? 2. Do you have any unsteadiness on your feet, or have difficulties with your walking or balance? OR Has the screener observed any unsteadiness or difficulties with the persons walking or balance? 3. Did you experience a blackout or any dizziness/ light- headedness when you fell? 4. Have you experienced any difficulties carrying out your usual activities since you fell? 5. Are you worried about falling again? 6. Were you unable to get up from the floor after you fell? If the answer is YES to any of the above questions in the shaded boxes, further assessment is required and a level 2 falls assessment needs to be completed. Please ensure the person is aware of this and is agreeable to further input. Additional comments regarding Level 1 Screening e.g. environmental issues/ hazards/ social issues/ cognitive or hearing and visual impairments etc: Is the person Housebound? YES NO CONSENT TO SHARE INFORMATION: The person has given informed consent (Information Sharing protocol: ISP) to share with: Health Social Work Leisure Other (specify) : YES NO Written consent obtained date: Declined/not obtained ( delete as applicable) Verbal consent obtained date: Falls Register information leaflet supplied: Yes/No NO FURTHER INTERVENTION REQUIRED REQUIRES LEVEL 2 ASSESSMENT LEVEL 2 ASSESSMENT ALREADY COMMENCED BY REFERRER PERSON DECLINED FURTHER INPUT SCREENERS INFORMATION Name: Service/ Dept/Team/ Practice: Location/ Address: Contact telephone number: Designation: Supply person with falls information and send completed level 1 screenings to: FALLS REGISTER Via MiDIS or Secure falls.register@lanarkshire.scot.nhs.uk Date level 1 screening completed:

14 PROPOSED LANARKSHIRE COMMUNITY FALLS PATHWAY SupporOng health improvement and self management to reduce the risk of falls and fragility fractures Level 1 Responding to an individual who has just fallen and requires immediate assistance and/or idenofying an individual at high risk of falls and/or fragility fractures Level 2 Co- ordinated management including Specialist assessment, mulofactoral IntervenOons with consideraoon of Telecare/Telehealth Level 3 Co- ordinated management including Specialist assessment Public Health InformaOon Health PromoOon Leisure Level 1 Screening Completed by:- Health staff SW staff Level 2 completed by professionals with relevant skills no referral required via admin Risk IdenOfied by Level 1 screening Tool passed to Admin for addioon to register and onward referral No further IntervenOon Indicated. Passed to admin for addioon to register Level 2 Assessment registered once complete Admin adds to register and directs to relevant team for Level 2 assessment if indicated (DN, CPT, ICST, SW OT, CARS) Level 3 Highly specialist Falls Assessment Falls Clinics Highly Specialist Falls Team Falls informaoon InformaOon transferred to register intervenoons offered which will support on- going self- management Dra? Community Falls PathwayDec2013

15 Progress/future plans Service user/carer focus groups- 27 th and 28 th March Staff awareness sessions completed in roll out area Joint posts agreed with NLC and NHSL for Register team Test register and pathway May 2014 Start register June/July upon recruitment of staff Roll out to other areas as momentum increases Develop register to include level 2 multi factorial assessment tools

16 Any Questions?