West Dunbartonshire HSCP‘s care and support for older people is delivered through our integrated Community Health and Social Care service, with a single Head of Service managing all aspects of community provision.

 

Key services and staff including District Nursing, Care at Home, Care Homes, Care at Home Pharmacy, Allied Health Professionals are organised to better share their professional skills and knowledge and best meet the needs of their patients, with crucial links to GPs and community pharmacies.

 

This includes:

 

• Effective communication between hospital, GP, community pharmacist, Care at Home staff and patient.
• Integration in the delivery of end of life care by home care and district nursing services.
• Preventing admission to hospital through nurse-led management of interactions to maintain the patient at home or in a local care home.
• Maximising the safe and cost-effective benefits from medicines, ensuring that patients take medication as prescribed, also potentially preventing hospital admissions.
• A Care at Home pharmacy service providing targeted pharmaceutical interventions to patients recently discharged from hospital and receiving Care at Home Services.
• A dedicated Palliative Care District Nursing Team training and supporting a wide range of health and social care staff in key aspects of palliative care.
• Using a wide range of skills and knowledge to support people’s choices when dying or have long term complex conditions.
• The Palliative Care District Nursing Team visiting each local care home on a weekly basis to help them address any palliative care issues they have, support staff to continue their learning and provide their residents and carers with the best care to meet their needs.

This is a truly integrated service which supports and cares for individuals and their carers through a difficult and complex time, providing them with a number of services through route. The complexities in developing and delivering such a service should not be underestimated, but the positive outcomes for families are clear.

 

During 2015/16, 35% of cancer deaths and 42% of non-cancer deaths occurred in hospital; and 62% of people on the Palliative Care Register were supported to die at home. All patients with palliative and end of life care needs have an anticipatory care plan and electronic palliative care summary completed within EMIS, which is then shared with relevant NHSGGC Acute services and the Scottish Ambulance Service to ensure a joined up approach within and outwith the HSCP.

 

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Success of this approach has received recognition regarding its innovative approach to integration. Winning a 2015 Special award for innovation at the NHS Scotland  Leading Integration for Quality event, judges commented that:

 

"This initiative demonstrates everything that integration is about – person centred, compassionate care for people. It brings together all sectors and agencies, and through training ensures that staff can confidently provide the best quality of care to people at the end of their lives."

 

“My mother’s very strong wish to remain in her own home was only achieved due to the magnificent service and support my mother received. Your carers are cheery, efficient, respectful and certainly know the meaning of ‘care’. What a wonderful team."

 

“All too often we take for granted the services provided. I wish, as do my brothers and wider family, to express my grateful appreciation, praise and thanks to your carers for the assistance given to my late mother. The council should be justifiably proud of this service."

 

“Quite simply, they made a tremendous difference to [my wife] and the rest of the family. I really cannot sing their praises enough, every one of them was an absolute star.”