Lead organisation:

NHS Lanarkshire

Project summary:

NHS Lanarkshire piloted a drop in clinic within the East Kilbride locality as a new model of service delivery for patients suffering from an acute episode of low back pain.

The drop in clinic is the first point of contact for patients who present to their GP with an acute episode of low back pain, thus reducing the delay for triage and advice. With early access to screening questions and objective testing, any patients who require medical review or intervention can be signposted to the appropriate service.

As a high percentage of back pain settles without physiotherapy treatment, appropriate patients can be issued with evidence based advice and guidelines to enable effective self management.

The clinic will enhance the available capacity of the clinicians involved thus enabling more new patients to be seen within a session than the historic 1:1 model. This will be evaluated with the opportunity to replicate the clinic throughout NHS Lanarkshire.

This project has finished. You can read more about it here.

Lead organisation:

Clackmannanshire and Stirling Health and Social Care Partnership

Partnership organisations:

NHS Forth Valley, Clackmannanshire Council, Active Clacks

Project Summary:

This project reaches across the prevention, primary care and secondary care spectrum and is part of an attempt to achieve a "best in class" system based model initially for people with lower limb joint problems. The aims are to support 1500 people who self-assess and select or are enabled to engage with evidence based community based support/interventions (e.g. exercise, stress management, weight loss) before reaching a GP or secondary care referral, reduce by 5% from baseline associated demand for physio and GP appointments, reduce by 10% referrals to orthopaedics and increase by 5% the proportion of people seen by elective orthopaedic services who are ready for surgery. They will design a Cluster and Locality based model with early redirection to self-care including activity options within the community.

This project is ongoing. You can read the latest update here.

Lead organisation:

STRiVE

Partner organisation:

East Lothian Health and Social Care Partnership

Project Summary:

This project will embed the use of volunteers and build social capital into the East Lothian Care Pathways for the Care at Home Project, with a particular focus on joint working with the home assessment and rehabilitation team on early supported discharge. A Community Support Programme as a key element or arm of the service, focusing on non-medical and practical support interventions, will support a return home and a return to their community in such a way that they are safe from harm. By providing daily contact and the availability of assistance from a volunteer or nominated person (for an agreed period) we will assist in providing a lower dependency or reliance on care services, and assist in maintaining people’s health and well-being. In addition to daily telephone contact and support, included is the opportunity for the person to request practical assistance – e.g. shopping, cooking, or support to participate in gentle exercise.

This project has finished. You can read more about it here.

Lead organisation:

NHS Greater Glasgow and Clyde

Partner organisations:

Bliss Neonatal Charity, Glasgow Children's Hospital Charity, Scottish Book Trust

Project Summary:

Family Integrated Care (FIC) is an innovative model of neonatal care that supports families to be primary caregivers for their baby, in partnership with the clinical team.

Helping Us Grow (HUG) is a unique collaborative of neonatal staff and families, working together in the Neonatal Unit at Glasgow’s Royal Hospital for Children to develop their model of FIC.

A grant from the ihub’s improvement fund is giving key staff dedicated time for rigorous testing and measurement of the HUG models processes and outcomes, with the aim to support 100% of families (or carers) in the Neonatal Unit to be primary caregivers for their baby by June 2019.

This project is ongoing. You can read the latest update here.

Lead organisation:

Midlothian Health and Social Care Partnership (HSCP)

Partner organisations:

British Red Cross and other third sectors partners in Midlothian

Project Summary:

Midlothian HSCP has worked with HIS to test the electronic Frailty Index (eFI). Initial work suggests that Midlothian has 10 000 people living with frailty and of these, 8000 are living with mild frailty.

This proposal will use analytical capacity and quality improvement methodology to use the eFI in identifying people with mild frailty and establish a robust pathway into community-based support, as well as inform future plans for this population.

For primary care, the focus will be on three GP practices, who will use the tool at practice-level to connect their patients into a holistic assessment offered by British Red Cross. Red Cross have the expertise to provide the time, support and onward connection for patients to Midlothian’s network of community-based services. For the H&SCP, a clearer picture of who this population is, how they use services and their unmet needs should emerge as the work progresses.

This project is finished. You can read more about it here.

Lead organisation:

Artlink

Partner organisations:

Midlothian Health and Social care Partnership

Project summary:

Artlink worked with Midlothian HSCP to test whether the arts process as a tool would support greater interaction, understanding of and shared learning with individuals with Profound and Multiple Learning Difficulties (PMLD).

Providing a practical programme of 4 artist-led creative projects to service users within Cherry Road Centre, they examined the ways collaboration informs how people with PMLD and their carers can effect, change and improve the service they receive.

This project has finished. You can read more about it here.

Lead organisation:

NHS Greater Glasgow & Clyde

Partner organisations:

Health Protection Scotland, Lanarkshire Health Board

Project summary:

A previous small pilot in 11 GP practices in NHS Greater Glasgow and Clyde (NHS GGC) demonstrated a small but significant improvement on flu vaccination uptake when individualised feedback to practices was provided on their last year’s performance and review of their procedures.

NHS GGC undertook a 12 month project to encourage all GP Practices, with below average flu vaccine uptake, to self-audit their flu vaccine processes and share and disseminate an individualized feedback report with recommendations to improve uptake. The rationale was to develop what lessons could be learned to develop a collaborative approach to improve seasonal flu uptake in future seasons

This prject has finished. You can read more about it here.

Lead organisation:

Glasgow City Health and Social Care Partnership (North East Locality)

Partner organisation:

GEMAP Scotland Ltd, Glasgow Centre for Population Health, Deep End, Associate Clinical Director NHS GGC

Project summary:

Previous piloting of an embedded advice worker in two GP practices demonstrated that it can significantly increase referrals to advice services and provide patients with a quality service that alleviates poverty and meets their needs in a confidential and anonymous way.

This project scaled up the model within the Parkhead cluster area to address poverty by embedding a Money Advice worker in each GP practice a half day a week. The worker took referrals directly from the practice team, supporting the aspiration that practices will function with wider multi-disciplinary support.

Embedding advice and supporting practice ownership made a significant difference to referrals and the reach of advice services. Outcomes included income maximisation, mitigating welfare reform changes, supporting debt management and financial capability.

This project has finished. You can read more about it here.

Lead organisation:

Dundee Health and Social Care Partnership

Partner organisations:

Integrated Substance Misuse Service Team, Blood Borne Virus Managed Care Network

Project Summary:

This project proposes to provide person-centred mentorship to improve the health of an extremely hard to reach cohort of people. Effective mentoring has the opportunity to improve people’s life skills, their lifestyle, encourage them to attend appointments and physically accompany the patient to appointments if necessary. People with hepatitis who are not engaging with secondary care services will be targeted proactively from one and if necessary two Deep End practices in Dundee (telephone, letter and opportunistic encounters). They will be verbally consented by a clinician to establish if they would be willing to be offered intensive mentoring input via the integrated substance misuse service team with a view to improving their quality of life and wellbeing.

This project has finished. You can read more about it here.

Lead organisation:

NHS Lothian

Project Summary:

Obstetric and diabetes staff have worked together to identify up to 8 appointments per woman with Gestational diabetes (GDM) which could be delivered remotely, without the woman having to attend clinic. The total number of appointments saved per woman will depend on how early on in the pregnancy the diagnosis of GDM is made. This clinic will employ a software programme, called Diasend, which is already used within the diabetes service to allow patients to download their blood glucose readings at home so that a diabetes nurse can review the readings and contact the patient with advice on adjustment of their glucose lowering medication.

This project is ongoing. You can read the latest update here.

Lead organisation:

NHS Greater Glasgow and Clyde

Partner organisations:

NHS Lothian Homeless Practice, Streetwork, Simon Community Scotland, Cyrenians

Project summary:

NHS Greater Glasgow and Clyde worked with partners to introduce prescribing pharmacists and a street outreach worker for 1 year in Edinburgh and Glasgow with the aim of engaging and maintaining contact with people who are homeless, whether on the street, hostels, community venues or in 3rd sector hubs to offer a "Health, medicines and social care MOT".

Immediate access to preventative healthcare, prescribing for long term conditions and housing assistance, advocacy, benefits support, as well as food / clothing was offered while building productive relationships.

This project has finished. A summary will be published here soon. You can read the most recent update here.

Lead organisation:

NHS Greater Glasgow and Clyde

Partnership organisations:

Neuro Out Patient Physiotherapy

Project Summary:

This project aims to develop a pathway for neurological patients to be discharged home safely or remain at home and still have rapid access to specialist physiotherapy. Treatment will be needs based at a frequency tailored to the individual patients’ requirements. Telephone support / advice will be provided and where appropriate can be used as an alternative to a face to face consultation. From the outset patients will have home exercise / activity programmes tailored to their requirements. Joint goals will be set with the patients to ensure treatments are specific to needs and to monitor for improvement. The aim is that all neurological patients within NHS GGC requiring specialist physiotherapy services receive a rapid response ensuring timely discharge and support to remain at home.

This project is ongoing. You can read the latest update here.

Lead organisation:

Revive MS Support

Partner organisations:

NHS Lanarkshire, Health and Social Care Alliance Scotland, Digital Health & Care Institute and Scottish Centre for Telehealth and Telecare (SCTT)

Project summary:

Revive MS Support aimed to tackle the inequality of access to multiple sclerosis (MS) support services in Scotland by piloting remote access to services in Lanarkshire, allowing those currently unable to benefit from them through the use of technology.

This year long pilot enabled people with MS, their carers and families to access support and services, irrespective of their geographical location or level of mobility, through the Attend Anywhere web-based platform. 

These services were led by a multi-disciplinary team, including a complementary therapist, a speech and language therapist, a counsellor, a continence nurse and a physiotherapist.

This project has finished. You can read more about it here.

Lead organisation:

Edinburgh Health and Social Care Partnership

Partner organisation:

Voice of Carers Across Lothian

Project Summary:

Building on the success of initial tests of change: to support a total of 10 care homes in Edinburgh and their aligned GP Practices to adopt and embed a robust approach to discussing, reviewing, recording and updating residents’ Anticipatory Care Planning (ACP) / Key Information Summaries (KIS).

Looking to spread to a further 18 care homes across Edinburgh city and reduce avoidable hospital admissions by 10% by March 2019, as well as increase ACP and use of KIS by 30% in 4 community mental health teams and 4 locality based multi-agency teams in Edinburgh HSCP.

This project has finished. You can read more about it here.

Lead organisation:

NHS Lothian

Partner organisations:

Edinburgh HSCP, Midlothian HSCP, Community Pharmacy Scotland, Voice of Carers Across Lothian, Carr Gomm

Project Summary:

This project aims to collaborate with and build on the work of the award-winning NHS Lothian Patient Experience and Anticipatory Care Plan Team (PACT) which reduced unplanned hospital admissions by over 30% for the high risk cohort of patients.

By March 2019 it is the aim to achieve a 20% reduction in the 90-day and 6-month hospital re-admission rates for those at highest risk of re-admission following critical illness in Lothian. Each person identified using the post ICU pathway/toolkit risk assessment checklist who meets the criteria to be included will have a personalised anticipatory care plan (ACP) drawn up in collaboration with that, person, their carer and treating clinicians before discharge. The ACP will be uploaded onto the hospital TRAK IT system under the yellow alert triangle icon and will also be e-mailed to their registered GP in the format that is compatible with the Key Information Summary (KIS) so that it can be shared across in-hours primary care, out-of-hours services, NHS 24 and the Scottish Ambulance Service (SAS).

This project is ongoing. You can read the latest update here.

Lead organisation:

Inverclyde Health and Social Care Partnership

Project Summary:

This opportunity will be used to lay the ground work for wider changes to Inverclyde’s moving and handling response longer term. The aim is to fully understand all creative moving and handling solutions and assess the benefits of enablement for individuals as well as impact on their independence and need for moving and handling support. They plan to examine all new double care requests (i.e. where two people are required to provide care) over 1 year and measure initial care package against care package required at transition from the reablement service related to moving and handling.

This project is ongoing. You can read the latest update here.

Lead organisation:

Ardgowan Hospice

Partner organisations:

Inverclyde Health and Social Care Partnership, University of the West of Scotland

Project summary:

Many people with palliative conditions in the community have unidentified needs. A recent study showed community patients tended to have their physical needs met but communication needs with health care professionals were unmet. Other studies have shown that psychosocial and spiritual needs of palliative patients and their families are not identified as they are reluctant to raise these issues in primary care.

If these needs cannot be met in the community by the primary care team then identification of these specialist needs and referral on to specialist palliative care services is likely to be beneficial.

This project tested the use of a patient-reported outcomes measurement tool - the Integrated Palliative Outcome Scale (IPOS) - to improve the understanding and assessment of palliative care needs of patients in the community by the primary care teams.

Using this tool, people will have their needs identified, interventions offered and outcomes monitored in an evidence-based way and, if required, be referred to a Supportive Care Clinic staffed by specialist clinicians from Ardgowan Hospice.

This project has finished. You can read more about it here.