The Scottish Government's vision is that by 2020 everyone is able to live longer, healthier lives at home, or in a homely setting. It promotes prevention, anticipation and supported self-management, and an emphasis on ensuring that people who are admitted to hospital are able to return to their homes or a community environment as soon as is appropriate, with minimal risk of readmission.
Living Well in Communities focuses on four key population groups:
- people with frailty
- people with palliative care needs
- people living with multiple long-term conditions, such as chronic obstructive pulmonary disease
- people with chaotic lifestyles
Our work is centred on five themes:
Living Well in Communities has a range of current and completed programmes grouped under these themes:
- Finding opportunities for improvement - Pathways for High Resource Individuals
- Identifying People before a crisis - Frailty and Falls in the Community, Palliative Care
- Planning for the future - Anticipatory Care Planning, Palliative Care
- Implementing preventative models of care - Frailty and Falls in the Community, Palliative Care, Neighbourhood Care, Intermediate Care
- Building local capacity and capability - all of our programmes, and our forthcoming regional work.
We are currently shifting to regional working with health and social care partnerships in the North, East and West of Scotland.
NHS boards, Health and Social Care Partnerships, the third sector and the independent sector.
Benefits of programme
We support the delivery of local priorities within the integration of health and social care, and aim to have an impact on the six measures of integration:
- unplanned admissions,
- occupied bed days for unscheduled care,
- A&E performance,
- delayed discharges,
- end of life care, and
- balance of spend across institutional and community services.