The AHP National Delivery Plan in the Western Isles.

The AHP National Delivery Plan in the Western Isles

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At 31 March 2015:At 1 October 2014:

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Our indicators:

Our red indicators:

Joint working with social care not fully developed;

Informatics recording poor

What we changed:

Implementing Topas system

Working with health intelligence team to improve recording and reporting

Working with Social Care around reablement, discharges, multi-disciplinary training

What we did:

• No big secret• Most of the work was being done already• Mapped and co-ordinated our activities • Identified gaps• Developed plans and pathways

What we do very well:

Deliver services seamlessly across health and social care throughout hospital and community

Meet 18 week waiting time target

Open referral, including self referral, to all servicesInnovative and flexible, exploring alternative solutions

See patients!!

7117

new patients across five services in the last year!!

We saw …

That’s 27% - 1 person in 4 living in the Western Isles saw one of our

AHPs in the last year!

Examples of local change

in the last three years:

Motiv 8Jump StartHenry – (Healthy Eating and Nutrition for the Really Young)Jungle JourneyEarly Years CollaborativeMaternal & Infant Nutrition

Children and Young People

Pain Management

• Extended Scope Practitioner - the only physiotherapist in Scotland carrying out spinal injections, freeing up orthopaedic surgeons’ time and cutting waiting times for patients

• Chronic Pain Programme

Falls, Reablement and Older People

Multi-agency Falls Policy

Dementia Pathway

Development of multi-service falls pathway – Physio, OT, Podiatry, A&E and Scottish Ambulance Service

OT Reablement Project – now delivering training to Social Care

Nutrition and DieteticsLow FODMAP diet for Irritable Bowel Syndrome

Breath testing to identify intolerances

Nutritional Care Pathway in the Community

Working with care homes to improve nutritional status of residents

Speech & Language Therapy

Dementia: “Caring to Communicate” Training for community nursing staff, carers and voluntary sector

AAC Roadshows: Promoting Access to Alternative and

Augmentative (AAC) communication support

Keeping your feet sweet

Developed programme for carers, of personal footcare and skin care, working with Western Isles Community Care Forum to train trainers

Development Posts for Extended Scope Podiatrists for MSK and Diabetes

RadiologyDEXA Service: - patients no longer have to travel to Dingwall for a bone scan

New high end ultrasound machines – parents can see high definition 3D scan of their unborn child

An existing member of staff trained as a sonographer and qualified in obstetric ultrasound in July 2015, to beat the recruitment challenge

In the wider community • Fully integrated multi-disciplinary cardiac rehab and

pulmonary rehab service in Stornoway and Benbecula

• Fatigue Management Programme

• Vocational rehabilitation

Joint Improvement Team Review of Community Equipment Service – creating a modernised, more effective and efficient service for all

Developing Technology

Telehealth – using Jabber for dietetic clinics and offering telephone appointments and email reviews

Expansion of Telecare

Topas appointments system – now we can track patient journeys and arrange dual appointments so patients

can see everyone they need to at the same time

Next StepsIntegration – will help us support older people and those with disability and complex needs to live independently in their own home/homely setting for as long as possibleDementia Managed Care NetworkEarly Years CollaborativeBuilding a sustainable workforce – making sure we always have the people with the right knowledge and skills to support people to live active and independent lives in community settings