2017-2018 Funded projects
10 projects across Scotland have been awarded this year from the Improvement Fund.
The fund was set up in September 2017 to support projects at a local level that improve the quality of health and social care services in Scotland. This year’s application process resulted in 131 Expressions of Interest, making the selection process highly competitive.
- Supporting community recovery following critical illness and reducing unplanned hospital admissions
Lead organisation: NHS Lothian
Partner organisations: Edinburgh HSCP, Midlothian HSCP, Community Pharmacy Scotland, Voice of Carers Across Lothian, Carr Gomm
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).
- The HUGG model of family integrated care
Lead organisation: NHS Greater Glasgow and Clyde
Partner organisations: Bliss Neonatal Charity, Glasgow Children's Hospital Charity, Scottish Book Trust
Family Integrated Care (FIC) is an innovative model of neonatal care that supports families to care for their baby in partnership with the clinical team. The team currently contribute beyond their normal clinical roles and are ready to take the project to the next level. This will allow key staff (HUGG Co-ordinators) dedicated time to support the plan for rigorous testing and measurement of the model of HUGG-FIC and to embed the most effective components in their Unit and share transferable learning and innovation throughout Health and Social Care in Scotland.
- Supporting care homes to embed a robust Anticipatory Care Planning (ACP) approach in Edinburgh
Lead organisation: Edinburgh Health and Social Care Partnership
Partner organisation: Voice of Carers Across Lothian
Building on the success of initial tests of change (2 phases): to support a total of 10 care homes in Edinburgh and their aligned GP Practices to adopt and embed a robust anticipatory care planning 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.
- Using the electronic Frailty Index (eFI) to identify people with mild frailty and develop a third sector led response
Lead organisation: Midlothian Health and Social Care Partnership (HSCP)
Partner organisations: British Red Cross and other third sectors partners in Midlothian
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 order to identify 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.
For further information, please contact Sandra Bagnall at Sandra.Bagnall@nhslothian.scot.nhs.uk.
- Mentoring frequent non attenders with hepatitis in a deprived area
Lead organisation: Dundee Health and Social Care Partnership
Partner organisations: Integrated Substance Misuse Service Team, Blood Borne Virus Managed Care Network
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.
- Best in Class Approach to Management of Lower Limb Arthritis
Lead organisation: Clackmannanshire and Stirling Health and Social Care Partnership
Partnership organisations: NHS Forth Valley, Clackmannanshire Council, Active Clacks
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.
- Rapid Access Specialist neurological physiotherapy service
Lead organisation: NHS Greater Glasgow and Clyde
Partnership organisations: Neuro Out Patient Physiotherapy
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.
- Piloting a nurse-led virtual clinic in the diabetes antenatal service
Lead organisation: NHS Lothian
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.
- Improving care - Opportunities to move to tailored single handed care solutions
Lead organisation: Inverclyde Health and Social Care Partnership
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.
- Community support programme for early discharge
Lead organisation: STRiVE
Partner organisation: East Lothian Health and Social Care Partnership
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.