active and independent living falls programme monthly ...€¦ · commence scoping of falls...

Active and Independent Living Falls Programme Monthly Report November 2017

07/11/2017 Active and Independent Living Programme 1


30 Health & Social Care Partnerships actively participating 25 SAS Area Service Managers /Team Leaders/Specialist Paramedics as Project Champions Supporting Mechanisms • National data distributed to all project leads • Progress Reports from the HSCP/SAS project teams • Monthly Flash Report & topical Webex led by National Team • Ongoing site visits/telephone support by AILP and LWiC to local project teams • National learning sessions (25th November 2016, 31 August 2017) • National works streams including economic modelling and development of

training resources.

SAS Falls & Frailty Pathways Work Stream


This specific programme contributes to: Towards 2020: Taking Care to the Patient (Scottish Ambulance)

The Prevention and Management of Falls in the Community: A Framework for Action for Scotland 2014/2016

Health and Social Care Delivery Plan 2016

Primary Care Transformation Plan

Policy Context & Work Stream Links


To AHPs Community falls assessment and rehabilitation staff will see

people earlier, when more likely to respond to interventions.

To Primary Care Community rehabilitation staff rather than GPs will arrange,

provide or refer for any further support that is required. For example, physiotherapy and occupational therapy, installation of a personal alarm, home adaptation, eye health checks.

Fewer people will look to General Practice or Emergency Social Care as first point of contact in case of concern or difficulties in the days or weeks following their fall.

To Acute Services

In all areas SAS crews will provide access to multi-factorial falls assessment for all people left at home following a fall. This will reduce likelihood of future falls and A&E attendance.

In many HSCP areas SAS crews will have access to same day community-based alternatives to A&E.

Benefits

Multi-agency leadership and governance to develop,

embed and sustain the pathway.

Local QI knowledge and support to facilitate

improvement.

Engaged, competent and confident frontline work

force with support to take decisions re conveyance.

•Agreement of aims and goals of the pathway. •Application of appropriate improvement methodologies, with QI support when required. •Measurement to understand the system and monitor activity and change.

•Consistent SAS leadership at all levels . •A local multiagency group overseeing the development of the pathway. •Clarity and agreement of roles & responsibilities of contributing partners in the pathway. •A local multiagency group monitoring pathway activity and outcomes (including adverse incidents) and responding to findings.

•Training and information for SAS staff to improve their understanding the aims of the pathway, how it works and the benefits to service users and the system, and to enhance clinical decision making. •Effective communication to SAS staff of the local pathway and parameters. •SAS and community staff understand roles and challenges of others delivering the pathway. •Decision making support, including ehealth and other technology support.

Simple, quick access to integrated community-

based services providing the right support.

Stakeholder engagement including service users and

carers.

•Community coproduction. •Mechanism for service user feedback. •Information about the pathway for the public. •Information provided by SAS at point of care.

•Clarity around consent. •A single point of access 24/7 to integrated community services. •Systems in place to receive, acknowledge, record and respond to referral from SAS. •Rapid telephone triage to ascertain response required. •Co-ordination of the community response including GP involvement. •Services providing an immediate/crisis response - to enable a person to remain in their home or close to home. •Multidisciplinary/ multi-agency services providing a planned response within a defined timescale - to enable recovery, restore independence and prevent further falls.

SAS Falls/Frailty Pathway Driver Diagram

What drives pathway development and implementation?

Key elements (Identified from scoping)

AIM

TO improve the experience and outcomes of people the SAS respond to following a fall and/or with frailty.

BY the SAS providing access to the most appropriate support and care at the time of the response.

THROUGH a simple and coherent pathway . Nationally, by end of October 2017: • the SAS will refer 50% of people aged 65+ they leave at home following a fall to community services for further assessment and support. •there will be a 10% reduction in the conveyance to hospital of uninjured people aged 65+ who have fallen.

February 2017 24/10/2017 5 Active and Independent Living Programme

Progress Status by HSCP area

Pathway operational - 30 Pathway agreed - 1 Pathway Planning - 1

Edinburgh City East Renfrewshire Shetland

East Lothian

Midlothian

West Lothian

Aberdeen City

Moray

Aberdeenshire

Western Isles

Orkney

Highland, Argyll & Bute

Dumfries & Galloway

Glasgow City

East Dunbartonshire

West Dunbartonshire

Inverclyde

Renfrewshire

N/S Lanarkshire

Perth & Kinross

Angus

Dundee

Fife

N/S/E Ayrshire

Borders

Stirling & Clacks/Falkirk

Based on October Progress Reports

Partnerships in bold fully spread

24/10/2017 6 Active and Independent Living Programme

Project Plan – Milestones – SAS Falls Insert Planned Milestones – Colour green if complete, red if overdue

7

Sep17 Oct17 Nov17 Dec17 Jan18 Feb18

ePRF Falls Screen go live JRCALC Guideline on Falls in Older People due for publication Report on economic modelling to Directors Validate integration of SAS attendance data and ISD hospital attendance/ admission data Complete first Test of Change of ePRF to Falls team electronic communication (Lanarkshire) Webex: Sustainability Workshop for SAS project leaders

Complete delivery of Sustainability Plan Falls and Frailty pathways go live on the SAS Pathways App Economic Model framework to be completed (revised date) Complete second Test of Change of ePRF to Falls team electronic communication (Lanarkshire) Webex: Quality Improvement

Interim Report on achievement against national action group improvement aims to AHP Directors SAS Falls Leads learning session. Further deep dive analysis at more HSCP areas – West Lothian, Edinburgh City, Perth, Aberdeen City Forth Valley go-live Fife go-live ePRF Falls Screen go live Webex: Successes and Challenges case studies

Complete analysis of Economic Model by partnership (revised date, SAS / ISD data validation delayed analysis) Completion of report on SAS Staff Survey (SAS leading) Further deep dive data analysis at more HSCP areas – East Lothian, Forth Valley GGC go live

Monthly: Compile and distribute Flash report to all HSCPs. Run topic centred Webex. National Coordination Team Meeting. 24/10/2017 Active and Independent Living Programme

Further SAS Improvement Leaders workshop Pan- Lothian SAS Falls sustainability meeting. Review Impact to date of programme within each HSCP area SAS electronic Patient Record Form database update due to complete Webex: Economic Model

SAS national and local reports due to be rewritten Determine QI support priority areas based on impact review of HSCPs Support further areas to complete deep dive analysis SAS electronic Patient Record Form database update due to complete Falls and Frailty pathways go live on the SAS Pathways App Webex: topic TBD

Key Performance Indicators


Code Definition

SAS Falls and Frailty Pathways Project

FallsAccess01 % of Community Referrals following SAS attendance to non-conveyed falls cases

FallsAccess02 # of Community Falls Multi-factorial Assessments

FallsAccess03 % reduction in conveyance to hospital following a fall without injury

Wider programme (in development)

H&W01 – Core: # of people accessing self-management information from identified data sources.

H&W02 – Core % of people reporting benefit from the information received.

PW01 – Core % of people seen by an AHP who are signposted into non health and social care services.

R&I01 – Core # of Falls Technology Initiatives aligned to The Scottish Centre for Telehealth & Telecare

Key Performance Indicator Report Quantitive: FallsAccess01


Category: ACCESS Improvement Programme Specific Measure Measure: % of Community Referrals following SAS attendance to non-conveyed uninjured faller

Aim: 50% by end March 2018



Category: ACCESS Improvement Programme Specific Measure Measure: % of Community Referrals following SAS attendance to non-conveyed uninjured faller


Measure Label: FallsAccess01 Data Source: SAS national data and HSCP locally reported referral data. Aim: 50% of all non-dangerous, non-conveyed cases. Issues / Risks: Culture change within SAS crews. Ability of crews to successfully identify suitable cases. Sufficient availability of community services to meet immediate needs. Spread and Sustainability: (where are you doing it now, where do you plan to go).

AILP, HIS and SAS IAs to work to together to build sustainability within local partnerships of SAS team leaders and community rehabilitation services. Comments: Aberdeen City, East Dunbartonshire, Inverclyde, West Lothian making significant progress with referral rates above 20%.

Key Performance Indicator Detail Quantitive: FallsAccess01



Category: ACCESS Improvement Programme Specific Measure Measure: % reduction in conveyance to hospital following an uninjured fall


Measure Label: Falls Access 03 Data Source: SAS national data and HSCP locally reported referral data Aim: 10% reduction from 57% to %47

Issues / Risks: Culture change within SAS crews Ability of crews to successfully identify suitable cases

Spread and Sustainability: (where are you doing it now, where do you plan to go).

AILP, HIS and SAS IAs to work to together to build sustainability within local partnerships of SAS team leaders and community rehabilitation services.

Comments: No shift in this measure to date, as crews are not yet familiar with the process of referral to community services. Anticipate that progress on this measure will follow significant success of FallsAccess01.

Significant variation in historic practice across all HSCPs with 40% to 68% of uninjured fallers being conveyed. Existing variation depends upon availability of uninjured pathways, future variation will remain for same reasons.


Risk Register – SAS Falls & Frailty


High Lack of

commitment/leadership

from some HSCPs or local

SAS teams to progress work

Lack of GP buy in

Lack of ongoing

maintenance & monitoring

of pathways

Loss of project leadership

within HSCPs

Unable to secure national

data sharing agreement

Crews do not use pathways

due to reluctance to change

practice and/or fear of

repercussions if ‘wrong’

decision made

SAS unable to release staff

for training resulting in poor

understanding of new

pathways.

Medium Referred cases need to be

admitted

Poor Case Finding

Patients decline referral

Delays to ePRF

Changeover to new data

system

Lack of visible and explicit

support from SAS senior

management

Loss of IA support from

national team.

Low Delays to SAS App Divergence in offer across

HSCPs

SAS divisional restructure (6)

Low Medium High

Impact

Probability

Good News Story


Edinburgh City Case Study 89 yr old lady fell, SAS attended, ensured lady uninjured and medically well. SAS referred to Edinburgh City Social Care Direct SPOA, which triggered installation of a temporary personal alarm pending further assessment. Subsequent to referral, Community Rehab representative attended patient’s home, conducted a MFA, arranged for patient to commence strength and balance exercises, and arranged for a permanent Community Alarm system to be installed in the home.

Project Plan – Milestones – Wider Falls Insert Planned Milestones – Colour green if complete, red if overdue Falls Leads Network Coordination Group Webex every 6 weeks


Oct 17 Nov 17 Dec17 Jan18 Feb18 Mar18

Community Falls Leads Meeting (Exercise) Commence scoping of Falls Prevention Learning and Development Guidance.

Workshop for development of falls prevention resources for Scottish Prison Service. Focus groups to review NHS Health Scotland’s Up and About booklet. Share findings of data dashboard project. Four nations falls summit in Wales. Commence evaluation of ‘Take the Balance Challenge’ Campaign.

Publication of Scottish Fire and Rescue Safe & Well Policy Agree membership of national group for consensus development. Agree membership of national expert group for 10 topics development and review of NHS inform falls pages. Recruitment of joint SAS/TEC Programme/AILP post to support joint working, spread and sustainability of uninjured falls pathways.

Community Falls Leads Meeting (Service Delivery Models) Publication of 10 topics (end March) First draft of consensus statement. Share evaluation of ‘Take the Balance Challenge’ Campaign. .

Balance Challenge: Third sector engagement. Virtual meeting with NZ Health and Quality Commission.

Balance Challenge: Targeted Pop Ups (RoSPA) Publication of Scottish Fire and Rescue Safe & Well Policy AHP NES Fellow in post Commence Data Dashboard Project with Argyll & Bute HSCP Falls Leads WebEx (Pathways for Fallen Uninjured)

Risk Register – Wider Falls Programme


High •Poor engagement

re Consensus

Statement.

Medium

Low

Low Medium High

Impact

Probability

What help do you need from SG leaders and across the AILP team?


SAS Falls • Raise visibility of work stream and achievements to date.

Wider Falls Programme • Raise visibility of work streams and achievements to date.

Appendices


Appendix A: National Falls Programme Logic Model Appendix A1: Health & Wellbeing activities Appendix A2: Access activities Appendix A3: Awareness activities Appendix A4: Partnership Working activities Appendix A5: Research & Innovation activities Appendix A6: Workforce & Practice Transformation activities

Falls Programme Logic Model Sept 2016 - Version 1 Scoping Inputs Outputs Outcomes

Situation Ambitions Priorities Resources Activities Short -Term Medium-Term Long-Term

Health & Well-being

Access

Awareness

Partnership Working

Research & Innovation

Workforce & Practice

Transformation

Drive and support the delivery of the Framework for Action 2014-16 Specifically: •Drive and support the implementation of SAS Falls and Frailty Pathways. •Engage and develop the workforce. Co-create a Framework for Action 2017-20

TEAM

Programme Lead (1 WTE)

IA

(0.5 WTE )

Partners/

Suppliers

ADSG

Community Falls Leads

Network

H&SCPs

SAS

LWiC (HIS)

TEC Programm

e

SFRS

BSC

The Alliance

Care Inspectora

te

Scottish Care

Public

3rd Sector

NOS

ISD

NES

NHS 24

Awareness Take the Balance Challenge Campaign, July 2017. Falls awareness week 2017: people working with older people. Falls, Fractures, Frailty & Osteoporosis Conference, May 2017. Publication of Falls and Fracture Consensus Statement, 2017 tbc.

Access

•Work with all H&SCPs, SAS , LWiC, the TEC programme and the Alliance to improve access to falls prevention and management services in the community setting, for older people the SAS attend following a fall (SAS Falls and Frailty Pathways Action Group). •Promote ‘Ask, Assess, Act’ approach, improve access to falls risk assessment and self management support.

Workforce & Practice Transformation •Develop a workforce competency framework for falls prevention and management. •Promote an outcomes based approach to falls prevention.

Partnership working •Work with Building Safer Communities, the third sector and Scottish Fire and Rescue to deliver primary prevention approaches. •Support and facilitate the Community Falls Leads Network.

Research and Innovation •Develop partnerships between delivery services, academia, industry, the DHI and SCTT. •On-going involvement in the European Innovation Partnership for Active and Health Ageing. •Raise awareness of new and emerging technologies to support falls prevention and management.

Knowledge Managem

ent •Capture and report learning and outputs from AILIP and other National Programmes •Report impact through AILIP and Falls Programme Measurement Frameworks •Communicate AILIP/Falls Programme through Managed Knowledge Network

Stakeholders

Older people and others at risk of falling Carers and families Older People’s services workforce H&SCPs Housing GPs NHS Boards Falls Leads Network SAS SFRS Care Inspectorate SSSC Scottish Care NES; HIS Third sector organisations incl Alliance National Policy makers Universities / Colleges (HEIs) AHP Federation International Partners Community Planners Improvement Bodies

The transformational learning around access will be spread to all AHP Services

AHPs will work in partnership with the people of Scotland to enable them to live healthy, active, and independent lives, by supporting personal outcomes for Health and Well Being. The ethos of Active and Independent Living will underpin all community development.

Assumptions

Monitoring and evaluation

Please refer to Individual Work streams for additional assumptions

Please refer to Individual Work streams for additional Measures

External Factors Please refer to Individual Work streams for additional external factors

Resources agreed and developed to support self management, early intervention for H&WB

The benefits of technology to drive self management, early intervention and H&WB will be spread Spread of multi-agency partnership working will be accelerated to support self management, early intervention for H&WB.

Population will have direct access to an AHP where appropriate

Population will have access to once for Scotland evidence based resources to support self management, early intervention for H&WB

Population will benefit from technologies to support self management, early intervention for H&WB

Population will benefit from multi-agency pathways to support their self management, early intervention for H&WB.

December 2017 December 2019 2020 and beyond

Appropriately skilled and developed workforce is contributing to the health and care needs of Scotland in a cost efficient and person centred way.

Health & Well Being •Review/update NHS Inform’s Falls Information Zone. •Support ongoing development of Falls Assistant appl •Produce/share widely short film on falls prevention. •Explore use of ‘brief interventions’ for falls prevention (in partnership with Public Health Wales). •Work with stakeholders on primary prevention focus in the Falls and Fracture Consensus Statement.

2016-2018

Testing of workforce tool and development of staff to undertake transformational change

Workforce tool influencing requirements and staff leading transformational change

Introduction of Health & Well-Being Outcomes Increased Focus on Personal Outcomes Lack of Awareness of the AHP contribution to H&SC Long waits to access many CYP & Adult AHP Services High number of population with disabilities not in employment Aging Population living with complex needs utilising more resources Underutilisation of technology to drive innovative practice Increased Demand on Health & Social Care Services Integration of Health & Social Care Increasing Challenges on GP and Primary Care Services Health & Social Care Workforce Challenges

24/10/2017 20 Active and Independent Living Programme

Appendix A1 – Falls Health & Wellbeing activities


• Review/update NHS inform’s Falls Information Zone. • Review/update of Up and About Booklet. • Support ongoing development of Falls Assistant appl • Produce/share widely short film on falls prevention. • Explore use of ‘brief interventions’ for falls prevention (in partnership

with Public Health Wales). • Work with stakeholders on primary prevention focus in the Falls and

Fracture Consensus Statement. • Work with RoSPA on workplace as a conduit for falls prevention

education.

Appendix A2 – Falls Access activities


Work with all H&SCPs, SAS , LWiC, the TEC programme and the Alliance to improve access to falls prevention and management services in the community setting, for older people the SAS attend following a fall (SAS Falls and Frailty Pathways Action Group).

Promote ‘Ask, Assess, Act’ approach, improve access to falls risk assessment and self management support.

Appendix A3 – Falls Awareness activities


Take the Balance Challenge campaign, from July 2017. Falls awareness week 2017 – targeting people working with older

people. Falls, Fractures, Frailty and Osteoporosis Conference, May 2017. Publication of Falls and Fracture Consensus Statement, 2017 tbc.

Appendix A4 – Falls Partnership Working activities


Work with Building Safer Communities, the third sector and Scottish Fire and Rescue to deliver primary prevention approaches.

Support and facilitate the Community Falls Leads Network. Work with Scottish Prison Service and Alzheimer Scotland on falls

prevention resource. Work with Technology Enabled Care Programme to improve falls

responder services. Partnership working is central to all activities in the Falls Programme.

Appendix A5 – Falls Research & Innovation activities


Develop partnerships between delivery services, academia, industry, the DHI and SCTT.

On-going involvement in the European Innovation Partnership for Active and Health Ageing.

Raise awareness of new and emerging technologies to support falls prevention and management.

Appendix A6 – Falls Workforce & Practice Transformation


Develop learning and development guidance for falls prevention and management (with NES).

Customise the NZ Healthcare Quality Commissions 10 Topics learning resource.

Work with UK College of Paramedics to develop falls elearning package.

Promote an outcomes based approach to falls prevention.

active and independent living falls programme monthly ...€¦ · commence scoping of falls...

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