Performance Detail

Supporting Care Needs at Home

Carers and Services

The falls service has continued to develop pathways in order to provide the recommended national multifactorial assessment to those identified as falling or being at risk of falls for people in Angus. Some of the key areas of improvement that the falls service has undertaken with their pathways are as follows:

• Emergency department to falls service pathway – virtual falls clinic developed on Trakcare, ensuring appropriate referrals from medical staff  within ED to the falls assessor, which have been consented to and received in a timely manner improving the  triage process and engagement with assessor for a better outcome.
• Scottish Ambulance Service continues to engage with the existing pathway, now having good representation within the Angus Falls Group and better communication between parties to share outcomes of individual assessment. *see case study
• Community Alarm to falls service pathway – recognised issues with receiving notifications of all fallers rather than detailed information which often meant delays in carrying out appropriate triage. There were also difficulties with training staff due to shift patterns etc so the falls service staff and control room team have developed a training link which has recently been disseminated to all community alarm staff to highlight the new pathway and process to follow. Pathway now requires a phone call referral requesting specific information similar to the SAS, which will ensure referrals can be made OOH and again are consented to thus improving engagement with the assessor. Under review at present.
• Falls Integrated Response and Technology Project – (FIRST) Pathway developed as recognised nationally there is a gap in services for those who fall are uninjured and do not need conveyed to hospital. Aim is to reduce unnecessary hospital admission and encourage use of telecare along with onward referral to the Falls Service. This meets the recommendations of stage 3 of the Tayside Falls Prevention and Management strategic Framework.
• Public engagement – Calendar with the inclusion of the recommended “Super 6” balance exercises produced end of 2019, and made available at GP surgeries and by community staff, to encourage fall prevention strength and balance exercises.
• Better balance classes – continued throughout all Angus localities until Covid 19 restrictions in place. Trialled use of Florence technology with group. All current attendees issued with the “Keeping Well at home Booklet” as recommended by the alter life training. Currently no classes taking place.
• Celonis – this system was used to identify a select group of individuals in south west Angus, with permission to review their fall -hospital -home journey. Outcomes highlighted that there were many other factors to take into account and what was coded as a fall on admission was sometimes due to other reasons such as a neurological/ alcohol related. It also highlighted examples of good practice of falls prevention work from MDT’s, prior to the event taking place.

Case Study

Situation

A 72 year old lady was referred to the Angus Falls service following attendance by the Scottish Ambulance Service overnight following 2x falls. Community Alarm had attended and had got the lady sitting up in a chair before the ambulance crew arrived. There was no medical reason for her to be conveyed to the ED at Ninewells hospital and so the crew followed the SAS-Falls service pathway and telephoned with the required details. This was picked up in the morning by the falls assessor.

The falls assessor carried out a phone call triage that morning, consisting of a multifactorial falls assessment, and it emerged that this lady had had 4x falls in the last two weeks and had only called community alarm and SAS for the last one.

Outcome

• Urgent referral to physiotherapy for balance and mobility assessment indicating the likely need for a walking aid.
• OT referral to community rehab team for bathing assessment as was now scared to use the shower due to loss of confidence following the fall, and also to provide a commode for overnight in the bedroom.
• Letter to GP to highlight recent falls and requesting review of continence as urgency overnight to toilet (falls happening overnight)
• Falls prevention literature sent out to the lady.
• Community Alarm service contacted as pendant band had broken so reluctant to wear.

A follow up evaluation call was carried out 2 months post triage. The lady had then been referred on for specialist assessment at the MFE clinic. She felt her confidence had been affected by the fall but that the measures above put in place had helped to increase her confidence and as a result, had had no further falls at this point.

End of Life Care

Angus has continually supported a higher proportion of people to spend the last 6 months of their life in their home or a care home compared to the Scottish average. Performance against his measure in Angus continues to improve as we deliver on the Angus Care Model and build our enhanced community support approach delivering integrated team working around GP practice supporting individuals.