2. Reshaping care and enabling independent living
"AHPs should be positioned in frontline service delivery and leadership roles to drive the reshaping of care for older people and post-diagnostic support for people with dementia. AHPs already straddle local authority and health settings and are the professional group with the right skill set to deliver on all of this."
Henry Simmons, Chief Executive, Alzheimer Scotland
Scotland has committed to establishing an integrated approach to planning and delivering health and social care services (Scottish Government, 2012). Scottish Government, the Convention of Scottish Local Authorities (COSLA) and other key stakeholders are working together to develop nationally agreed outcomes for integration of health and social care services.
Scotland's AHPs can and should make a significant contribution to reducing unnecessary hospital referrals and admissions and to preventing over-reliance on professional interventions in the future. National guidance on Maximising Recovery & Promoting Independence: intermediate care's contribution to reshaping care, a framework for Scotland (Scottish Government, 2012a) describes some of this work and has been developed through a partnership involving the Joint Improvement Team, the Chief Health Professions Officer and key stakeholders in rehabilitation and reablement across health and social care.
AHPs are strongly placed to support self-management and enablement and drive integration at the point of care. They have an "enabling" ethos that is rooted in a person-centred approach and sits in the spectrum between a "treatment-based" approach and a "care-based" model. They can be pivotal in creating a paradigm shift away from professional dependency towards resilience and an asset-based approach that builds personal capabilities and community resilience.
Reducing inappropriate admissions and unnecessary care costs are key to affordable and sustainable services in the future. AHP interventions can significantly reduce unnecessary admissions to hospital (through AHP services being based in accident and emergency departments, for instance) and reduce dependency on care services (through integration of rehabilitation and homecare services). An excellent example of this is the integrated falls and fracture care pathways spanning prevention and self-management, early identification of risk, avoidance of unnecessary admissions to hospital and other care settings and evidence-based secondary prevention.
Falls can have far-reaching consequences for an older person. Besides the pain, injury and distress experienced, there can often be a loss of confidence and independence. Such consequences can be life-changing for some (44% of care home residents are admitted as a result of frequent falls) and, for others, even life-limiting. Falls can nevertheless be prevented for many individuals, and an integrated approach to falls prevention can make a significant difference to the lives of the "at-risk" population. Good personal footcare makes an important contribution to this work, especially for people who are unable to care for their own feet and rely on carers or relatives, and this is a priority for people who use our services.
AHPs have always worked across health and social care sectors and organisational boundaries to focus on the needs of people who use services, their families and carers. AHP directors and leads working across health and social care will be key to enhancing the AHP contribution to the joint planning and delivery of services, particularly for those with complex needs, long-term conditions and dementia.
Telecare/technology will play an increasingly important role in supporting older people to live safely in their homes, particularly those with dementia.
Approximately 82 000 people in Scotland were thought to have dementia in 2011 (of whom 3500 were under 65 years). That number is projected to double over the next 25 years, with 7000 people in Scotland being diagnosed with dementia each year.
Scotland's National Dementia Strategy (Scottish Government, 2010a) is a key part of the wider agenda on reshaping care for older people and the delivery of an integrated system of health and social care services across Scotland. It was designed to make real and measurable improvements in dementia services and achieve transformation of care and people's experience in care, underpinned by a rights-based approach.
AHPs have the expertise to support people with dementia, their families and carers to live well with the condition through the promotion of supported self-management and provision of specialist functional assessments and environmental adaptations. They are well-positioned to lead on reablement, early and post-diagnostic intervention but will need support to build capacity and capabilities in and across sectors to enhance care pathways for people who use services, their families and carers.
We need to ensure that AHPs from health and social care settings are empowered to lead teams and direct delivery of this agenda. Improving post-diagnostic services is enshrined in a national commitment that will guarantee a minimum of a year's dedicated support for those diagnosed with dementia, their families and carers, coordinated by a named person.
A significant proportion of the Change Fund has already been invested in services led and delivered by AHPs. Further work is now required to evaluate the effects of this investment to determine which services have the greatest impact on service delivery.
| No. || Action by || Delivery by end of |
| 2.1 || AHP directors will work within their NHS boards to ensure dedicated AHP support is established within emergency admission services, in line with best practice for emergency care (RCP, 2007), to prevent unnecessary admissions to hospital. || 2014 |
| 2.2 || AHP directors will work within their NHS boards to support falls leads within CHCPs (and HSCPs as they emerge) to implement integrated falls and fracture care pathways to reduce falls-related admissions to hospital in the over 65s by 20%. || 2014 |
| 2.3 || AHP directors will work with directors of social work and their NHS boards to maximise the AHP contribution to achieving delayed discharge targets and reduce overall length of stay in hospital, which will support the delivery of the legal treatment time guarantee. || 2014 |
| 2.4 || AHP directors will work with directors of social work to support older people and those with disability and complex needs to live independently in their own home/homely setting for as long as possible, delaying or reducing admissions into institutional care. || 2015 |
| 2.5 || AHP directors will work with directors of social work to reconfigure "enabling" services, such as rehabilitation and reablement, to deliver best value and enhance care experiences for people who use services and their families and carers. || 2015 |
| 2.6 || AHP directors and AHP leads in local authorities, working in partnership with Alzheimer Scotland, will work to ensure the multisectoral delivery of early intervention and post-diagnostic support for people with dementia and their families and carers, in line with the national commitment. || From 2013 onwards |
| 2.7 || AHP directors will work with AHP leads in health and social care and partners in care organisations, voluntary services and older people's groups to implement the National Personal Footcare Guidelines once published in late 2012. || 2013 |