Living Well in Communities: Scoping and Design v1.0 · Web viewThe indicators are divided into two types of complementary measures; outcome indicators based on survey feedback, and,

Living Well in CommunitiesScoping and Design

Version 1.0

18 September 2015

Susan BishopNational Lead Primary Care, Community and Outpatients - QuEST

Head of Improvement Programmes - Joint Improvement TeamJune Wylie

Head of Implementation and Improvement - Healthcare Improvement ScotlandSarah Harley

Health Services Researcher - Healthcare Improvement ScotlandThomas Monaghan

Improvement Advisor - Healthcare Improvement ScotlandNathan Devereux

Associate Improvement Advisor - Healthcare Improvement Scotland

1. Executive Summary.....................................................................................................2

2. Context....................................................................................................................... 42.1. Introduction................................................................................................................................................4

2.2. Health and Welling Outcomes for Health and Social Care Integration.......................................................4

2.3. Commissioning Request..............................................................................................................................5

3. Scoping....................................................................................................................... 53.1. Development Group...................................................................................................................................5

3.2. Scanning......................................................................................................................................................5

3.3. Testing........................................................................................................................................................7

3.4. Collation, Prioritisation and Dissemination.................................................................................................7

3.5. Current Activities........................................................................................................................................8

4. Summary Outcomes....................................................................................................94.1. Priority Areas..............................................................................................................................................9

4.2. Theory of Change......................................................................................................................................10

4.3. Theory of Execution..................................................................................................................................12

5. Summary and Recommendations..............................................................................14

Appendices..................................................................................................................... 15Appendix I. List of Stakeholders.......................................................................................................................15

Appendix II. Mapping Activity...........................................................................................................................16

Appendix III. High Resource Individual Data..................................................................................................17

Appendix IV. End of Life Data.........................................................................................................................18

Appendix V. Evidence on Reducing Beds from a Hospital Setting.....................................................................19

Appendix VI. Evidence review........................................................................................................................20

Appendix VII. Contributing programmes.........................................................................................................23

Appendix VIII. Frailty and falls..........................................................................................................................25

Appendix IX. High Resource Individuals.........................................................................................................28

Appendix X. Anticipatory Care Planning............................................................................................................30

Appendix XI. Delayed Discharge.....................................................................................................................32

Appendix XII. Housing.....................................................................................................................................34

Appendix XIII. Health and Social Care Integrations Indicators.........................................................................36

Appendix XIV. References................................................................................................................................40

Living Well in Communities: Scoping and Design v1.0 1

1. Executive SummaryBackgroundThe Scottish Government’s vision is that by 2020 everyone is able to live longer, healthier lives at home, or in a homely setting. This vision is supported by the national health and wellbeing outcomes framework, which recognises the contribution that is required from a wide range of public services in Scotland to improve people’s health and wellbeing.

In November 2014, the former Cabinet Secretary for Health, Wellbeing and sport, announced an ambition “..to give back at least 200,000 days to individuals, families and communities..” that would otherwise have been spent in hospital. The ambition is to be achieved by December 2017.

The three national improvement organisations; Joint Improvement Team (JIT), Healthcare Improvement Scotland (HIS) and the Scottish Government’s Quality, Efficiency and Support Team (QuEST) were asked to combine their knowledge and expertise to co-design a range of activities that would contribute toward achieving the ambition.

Scoping A development group was formed, comprising of practitioners, subject matter experts and representatives from the Scottish Government, NHS boards, local authorities, third and independent sectors, and a public representative. An adapted 90 day three phase innovation process was selected to structure the scanning, focussed testing and dissemination stages.

The development group undertook a series of workshops, meetings and individual conversations to map existing programmes across health, social care and third and independent sectors. A range of evidence and data was collated and reviewed to inform the development group’s thinking and recommendations. Testing of the areas identified by the workshops, evidence reviews, and data analysis, was carried out through a co-produced deep dive exercise with a partnership.

The development group acknowledged that the volume and diversity of improvement activity already taking place and the complexity of the health and social care landscape, means that the focus areas identified for support through Living Well in Communities will seek to contribute to the shared outcome of enabling people to spend more time living in a community setting, but will not provide an overall solution.

Recommendations It was therefore agreed that the focus areas will be identified where the data, evidence and stakeholder engagement indicated that the pace and scale of improvement can be increased if additional improvement support is provided. The areas identified as meeting these criteria are as follows:

Frailty pathways and Falls management and prevention Anticipatory care planning Improving links between the housing sector, health and social care Elements of delayed discharge Pathways for high resource users of health and social care services

In addition to the five areas above, Dementia is recognised as an area of work that should be included within the portfolio. As discussions are taking place with Scottish Government Health Directorates about the future scope of this work, it is therefore agreed that dementia should be the focus of a separate scoping process which will report to the Scottish Government in autumn 2015.

The programmes that were identified by the development group as contributing to the overall aim but that will remain separate to the portfolio are detailed in the full report.


For the focus areas identified, improvement support will be divided in to two separate but complimentary elements:

Time-limited improvement support to increase the pace and scale of change across a portfolio of programmes that are already contributing to enabling people to live well in communities

Tailored and responsive improvement support for partnerships undertaking analysis of their current priorities, to determine gaps in meeting needs of people and places, with a view to supporting whole system review and redesign of pathways

This portfolio of work, named “Living Well in Communities”, will offer to help build conditions for improvement where they don’t already exist and support programmes within the portfolio moving through an improvement journey. Partnerships will be identified for each focus area, and improvement support provided to help diagnose, test and implement interventions and re-design pathways.


2. Context

2.1. IntroductionThe Scottish Government's vision is that by 2020 everyone is able to live longer, healthier lives at home, or in a homely setting. It promotes prevention, anticipation and supported self-management and a focus on ensuring that people who need to go to hospital get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

The Programme for Government (2014) includes the aim, as set out in a Ministerial commitment in November 2014, “to give back at least 200,000 days to individuals, families and communities by 2017 that would otherwise have been spent in hospital”1.

2.2. Health and Welling Outcomes for Health and Social Care IntegrationHealth and social care integration is underway with all arrangements to be in place by April 2016. The national health and wellbeing outcomes for Scotland have the overarching aim that health and social care services should focus on the needs of the individual to promote their health and wellbeing, and in particular, to enable people to live healthier lives in their community.

The Health and Wellbeing outcomes framework recognises the contribution that is required from all services in Scotland to improve people’s health and wellbeing. It promotes a system whereby health boards and local authorities, along with partners in the housing sector, the third sector and communities take a bottom up approach to designing and delivering better coordinated care. A coherent and integrated approach across national improvement support mirrors the integrated approach to achieving better outcomes that people expect to see in their communities and localities.

There is also a need to make best use of resource in delivering high quality care and support services through continuous improvement of outcomes, using improvement methods with the objective of ensuring that services are consistently well designed, and reliably delivered by the right people, to the right people, at the right time.

1 The Scottish Government (2014) Our Scotland – Programme for Government,Living Well in Communities: Scoping and Design v1.0 4

Figure 1 - Health and Wellbeing Outcomes for Health and Social Care Integration.

2.3. Commissioning RequestThe Person-centred and Quality Unit within Scottish Government has responsibility for policy development and support for policy implementation in relation to the aim “to give back at least 200,000 days to individuals, families and communities by 2017 that would otherwise have been spent in hospital”.

Three national quality improvement bodies; Healthcare Improvement Scotland, The Joint Improvement Team, and the Quality and Efficiency Support Team, were directed by the policy lead to use their combined resources and expertise to determine the scope of what needs to be done to achieve the aim and to design delivery support.

3. Scoping

3.1. Development GroupThe three improvement bodies brought together a co-chaired scoping and design team to co-ordinate and drive the work. The team formed a dynamic development group of practitioners, subject matter experts and representatives from Government Directorates, NHS, Local Authority, Third and Independent sectors and a public–patient representative to oversee and inform the scoping and design.

The scoping and design team reports through the co-chairs to the Directors of the improvement bodies and on to the policy leads in Scottish Government.

A development group was convened for the design phase of the programme, which brought knowledge and expertise together across health and social care services. Part of the responsibility of the development group was to oversee stakeholder engagement, which included reviewing a stakeholder map and agreeing engagement activities at each meeting. Stakeholders were scored against a matrix of influence and interest to determine the most appropriate form of engagement (See Appendix I List of Stakeholders on page 16).

3.2. Scanning

3.2.1. Mapping existing improvement and delivery programmes and initiativesThe development group undertook a series of workshops, meetings and individual conversations to map existing programmes across health, social care, Third and Independent sectors. Stakeholders were invited to add to the mapping exercise through face to face and telephone meetings. Visual management was used to chart and consult on the output of the workshops and engagement activities (See Appendix II Mapping Activity on page 18). In view of the level of interest partnerships have in older people services, including frailty pathways, it was agreed that a programme of work on Frailty should commence as soon as possible. It was therefore agreed that this area of work would be included in the Living Well in Communities portfolio.

3.2.2. Evidence scanA review of the evidence base was undertaken, which included literature known to the core team, the development group, and the range of policy delivery and improvement programme leads. A high level literature scan was also commissioned from HIS’s Evidence and Knowledge team. The key points from this search are included below.


A review of evidence of interventions that can lead to care closer to home:

o Early and supported discharge for older people

o Care at home and hospital at home interventions

o Assertive case management for long-term conditions and high service users

o Targeting people at high risk

o Self management

o Technology enabled care

The Scottish Association of Medical Directors commissioned an evidence review to assess the impact of health and social care integration and anticipatory care planning on reducing admissions and bed days for the frail elderly.

Ko Awatea 20,000 days campaign. The core team drew on the experience of the 20,000 days and beyond campaign at Ko Awatea, New Zealand. Conversations were set up with those responsible for designing and implementing the campaign to learn from their approach in engaging the community and measuring the impact of the programme.

Literature search on conditions and focus areas. Analysis of national data and intelligence identified a small number of long term conditions and multi-morbidity as a potential focus.

Housing strategy. The Joint Delivery Plan for Housing in Scotland sets out a range of actions required to enable the housing sector to make the strongest possible contribution to the health and wellbeing outcomes, by working with Partnerships both in strategic planning (at Partnership and locality level) and in delivery of services.

Systems thinking and design, improvement and implementation methodologies. The evidence scan included large scale change theories and methodologies, transformational change, Deming’s System of Profound Knowledge, use of Breakthrough Collaborative Improvement Programmes, Lean, design and innovation methodologies, and implementation research.

Health inequalities. The link between socio-economic deprivation, increased use of health and social care services, and poorer health and wellbeing outcomes.

3.2.3. Data diveA range of data and intelligence was collated from available sources by a unique collaboration of analysts from Information Services Division in National Services Scotland, the Joint Improvement Team and the Health and Social Care Integration Division in Scottish Government. The analysts worked together to provide the development group with a range of presentations and interpretations and rapidly responded to the need for iterations. This included data on cohorts of patients defined as high hospital and community prescribing resource users, generated from the Integrated Resource Framework database; an output of the Health and Social Care Data Integration and Intelligence Project.


3.3. TestingThe opportunity was taken by the design team to work with a health and social care partnership to undertake a ‘deep dive’ focusing on the concept of ‘person and place’. This is in line with the Scottish Government’s integration agenda, which is “about designing services around a person’s circumstances and their personal outcomes, ensuring that they experience the right care and support whatever their needs, at any point in their care journey”2.

A ‘deep dive’3 is a technique to “rapidly immerse a group into a situation for problem solving or idea creation”. It is a proven method for innovation in process improvement and often focuses on four distinct areas: process, organisation, culture and leadership.

This deep dive was co-produced with the partnership, and led by the Health and Social Care Partnership Integration Chief Officer. The workshop was attended by a range of staff representing Midlothian local authority and NHS Lothian. The group included the Clinical Director and Head of Healthcare and Strategic Planning for the health and social care partnership, and, the Integration Manager, Head of Adult and Older People Services and Falls coordinator for the local authority. Data analysts in Scottish Government and National Services Scotland’s Local Intelligence Support Team provided an initial series of data presentations then worked rapidly and responsively with the team to generate new data at their request. The process of undertaking a deep dive and feedback from the local and national teams has reinforced the benefits of using this approach to identify priority areas of focus for future pathway redesign.

3.4. Collation, Prioritisation and DisseminationThe accumulated knowledge was analysed and a summary of the quantitative data used to inform the design of Living Well in Communities is given below.

The number of emergency bed days used in Scotland has seen a gradual reduction from 4.11m in 2008/09 to 3.83m in 2013/14, however the number of emergency admissions has risen from 521,406 in 2008/09 to 542,805 in 2013/14

People aged 75 years and over are 4 times more likely to experience an unplanned admission per 1,000 of the population compared to those aged 45-54

60% of all deaths in Scotland are attributable to long term conditions and account for 80% of all GP consultations

On average, 70-75% of beds occupied through delayed discharge are by those aged 75 years and over

Falls account for approximately 390,000 emergency bed days a year

2% of the population were responsible for 50% of the hospital and community prescribing resource (2012/13). This 2% of the population were responsible for 77% of all inpatient bed days (Appendix III. High Resource Individual Data on page 19)

The average length of stay for people in the final six months of life differs by up to 10 days depending on where they live (Appendix IV End of Life Data on page 20)

2 A guide to support the local implementation of Health and Social Care integration – Communications Toolkit3 https://rapidbi.com/deepdivebrainstormingorganizationaldevelopment/#whatisdeepdive Living Well in Communities: Scoping and Design v1.0 7

https://rapidbi.com/deepdivebrainstormingorganizationaldevelopment/#whatisdeepdive

3.5. Current ActivitiesThe outcomes of the scanning and testing of the current system were used to map existing activities that contribute towards achieving the overall aim of Living Well in Communities.

Figure 2 below contains a map of current national programmes which relate to the aim of Living Well in Communities. In addition there will be a range of existing improvement initiatives within NHS Boards and Health and Social Care Partnerships which contribute to this aim. Appendix VII Contributing programmes on page 25 contains a description of each existing national programme.


Figure 2 - Map of existing activities that will contribute towards the aim of Living Well in Communities.


Technology enabled care

Primary care access

Palliative and end of life care

Whole system patient flow

Anticipatory care planning

Complex housing needs and housing

Dementia and mental health

High resource individuals

System relationships:Leadership and values, governance model and strategic commissioning. Cross-sector partnership working,

behaviours and relationships

Hospital:Access, admission, flow and discharge.

Community:Community capacity building, third

sector and community hospitals. Primary and intermediate care, self-

management, home care and housing support.

Population:Age, socioeconomic status, gender,

multi-morbidity. Changing demographics and home

environments

By December 2017 people will have spent more days in the community, at home or in a

homely setting, that would have otherwise been spent in

hospital.

Aim Drivers

4. Summary Outcomes

4.1. Priority Areas

The development group acknowledged the volume and diversity of improvement activity already taking place across the health and social care landscape and that there is already significant work in place that will contribute to the ambition of “giving back at least 200,000 days to individuals, families and communities by Dec 2017 that would otherwise have been spent in hospital”. In light of the broad range of improvement activities and initiatives which are currently being taken forward locally and nationally, the design group agreed to focus on areas where the data, evidence and stakeholder engagement indicated that the pace and scale of improvement could be increased if additional improvement support was provided.

In doing this, it is recognised that the overall aim will be delivered by a combination of the impact from the existing programmes of work at both a national and local level and those that are being initiated and strengthened through the Living Well in Communities portfolio.

The identified priority areas are listed in Table 1 below with more information on each priority area available in Appendix VIII to Appendix XII on pages 27 to 36.


Table 1 - Drivers recommended as priority areas for Living Well in Communities.Priority area Aim More detailFrailty and Falls To support partnerships to identify problems with current pathways for frail

older people, and test and implement innovative solutions to re-design whole system pathways that will enable frail older people to remain living in the community.

Page 27

High Resource Individuals

To develop and understand the current pathways and social resource use of those individuals with high resource needs, and identify areas for system wide improvement that will improve the care and experience for people, and their carers.

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Anticipatory Care Planning

To achieve person-centred care and personal outcomes for people with long-term conditions, by supporting partnerships to implement the use of Anticipatory Care Planning and increase access to Key Information Summary.

Page 32

Delayed Discharge To reduce the number of bed days occupied through delayed discharge, by supporting partnerships in identifying underlying causes and sustainably embedding the Delayed Discharged Expert Group recommended interventions, together with testing and implementing innovative solutions to redesign whole system responses across all sectors.

Page 34

Housing To support the implementation of the Joint Improvement Team’s Housing programme, and test a range of approaches to test innovative approaches to housing solutions that will contribute toward improving discharge pathways.

Page 36

Dementia is recognised as a national priority for Scotland and was identified by the core group as an area for inclusion within the portfolio of work. Discussions are currently taking place with Scottish Government Health Directorates in relation to the future scope and scale of improvement support for people living with dementia and it has therefore been agreed that dementia should be the focus of a separate scoping process which will report to the Scottish Government in autumn 2015. There is a strong interface between the Focus on Dementia Programme, Living Well in Communities and the Older People in Acute Care Programme, which will be taken into account when planning improvement support activities and measures.

4.2. Theory of Change

4.2.1. Theory of ChangeMultiple technical and human factors prevent changes or improvements from being made and spread, irrespective of these being small or large scale change (NHSIQ 2014). Learning from a range of initiatives has made it possible to build knowledge about how to create the right conditions for adoption and implementation of improvements. These conditions include: understanding current systems and processes, developing leadership for change, policy alignment, using networks and connections, assessing readiness for change, knowledge management, understanding intended and unintended consequences of change, knowing how to measure costs and benefits, and determining factors that will affect reliability and sustainability4.

4 Ovretveit 2013, Fixen 2005Living Well in Communities: Scoping and Design v1.0 11

4.2.2. ApproachRecognising the complexities of the current health and social care landscape and the broad range of improvement activities already underway across Scotland, the core group identified the requirement to take the following approach to improvement support:

Portfolio of Improvement Programmes: These are a portfolio of specific programmes, projects and developments which contribute to enabling people to live well in communities. On initiating the design phase it was thought that these would be additional programmes of work, however as the process progressed it became clear that many of the key issues already had initiatives/programmes in place so the focus moved to those which could more rapidly achieve or exceed their goals if provided with time-limited improvement support. As highlighted above, this portfolio does not include all the existing programmes which will contribute to the aim, but rather those where the data, evidence and stakeholder engagement indicated a priority need for increased focus and investment of improvement support

Tailored and Responsive Improvement Support: The design phase highlighted the importance of supporting Partnerships to map the current use of health and social care, and community support services, determine the opportunities for improvement to better meet the needs of people and places and, in response to those opportunities, test new approaches and interventions with the aim of enabling individuals to remain in a home or homely setting. It was recognised that tailoring the improvement support to each partnership is important for ensuring that the context and local priorities for each area are fully understood and used to inform the redesign/improvement work. Tailoring the approach to each partnership will also increase the opportunities for making best use of community assets

4.2.3. Design principlesA core group of principles have been identified and will be applied to all aspects of the improvement portfolio:

Focus on areas that will bring measurable improvements to personal experience and outcomes as well as greater efficiency in service delivery

Requirement to work on whole systems redesign to support more people being cared for at home rather than in hospital.

Requirement to review and use health and social care data, along with a range of local evidence (where this exists), to inform testing and design of improvement support

Requirement to understand local context and complexity when identifying areas for improvement5

Improvement activity will be co-produced with the partnerships

An appropriate improvement methodology will be identified for each focus area

To contribute toward shared outcomes, a learning-based evaluation must be identified to ensure that learning is captured and shared throughout the process.

4.2.4. Measurement and evaluationA core suite of indicators are being developed to support partnerships in measuring their impact on improving the population’s health and wellbeing6. The indicators are divided into two types of complementary measures; outcome indicators based on survey feedback, and, indicators derived from organisational/system data. A summary of the indicators and how they relate to the focus areas of Living Well in Communities is included in 5 Kaplan, H.C. and Greenhalgh, T.6 Core suite of integration indicators - http://www.gov.scot/Resource/0047/00473516.pdfLiving Well in Communities: Scoping and Design v1.0 12

appendix VII. The design team will engage colleagues in the Scottish Government to explore the options for a measurement framework that will draw on national indicators and those specific to LWiC. The measurement plan will continue to be informed by the intelligence obtained through working with partnerships, as we broaden our understanding of the types of data and evidence capture that is taking place locally. Development of the Health and Social Care Data Integration and Intelligence Project may also increase access to community based measures7.

The approach identified for measuring the impact of LWiC will be to see a reduction of at least 200,000 bed days against a projection of future demand based on population growth. The approach is informed by analysis of literature that suggests reducing actual hospital beds in the short term may be unrealistic in the UK context as it has high levels of bed occupancy rates (Summary of evidence attached as appendix V). A baseline will be established for the beginning of the implementation phase of Living Well in Communities and the population growth estimates from the General Register Office for Scotland applied to produce a projection of future demand.

Living Well in Communities consists of a specific range of improvement programmes, which span the health and social care landscape. Selecting an evaluation approach that can identify and evidence the specific contribution being made by a portfolio to shared outcomes is therefore important. The evaluation must also recognise the limits to evidencing the direct contribution being made to longer term outcomes due to the influence of external factors, such as existing improvement programmes which also seek to enable people to spend more time living in a community setting. Contribution Analysis has been identified as a suitable evaluation approach as it is a pragmatic way to plan and evaluate the activity of programmes in contexts which are characterised by complexity; such as a multi-partnership environment where multiple organisations contribute to shared outcomes. Analysis exercises will therefore be undertaken with key stakeholders during the design phase of the portfolio, and periodically throughout the implementation phase, to assist in articulating the theory of change through a participatory process, and to generate a chain of expected outcomes that will be central to the monitoring and evaluation framework.

4.3. Theory of Execution

4.3.1. Portfolio OverviewLiving Well in Communities will support partnerships to help build conditions for success where they don’t already exist and support initiatives and programmes within the portfolio moving through an improvement journey (understand, design, test, evaluate, sustain, spread).

HIS, JIT and QuEST’s Programme Directors, Associates and Action Group members will build on their existing relationships with teams and partner organisations within national and local government, health and social care, housing, third and independent sector to identify ways of providing additional tailored and time-limited improvement support for elements of the portfolio.

The process for agreeing additional support for partnerships will also be informed by the first round of deep dives.

A four step process will be applied to each of the priority areas:

Step 1 Using a system thinking approach for a current state assessment of the whole system; exploring the type and frequency of demand on the system and the capability of the system to respond to demand.

Step 2 Following through by mapping individual pathways, particularly of high resource users, to identify non-valuing adding steps and gaps in provision of information, care or services for individuals, groups of people and localities.

7 http://www.isdscotland.org/Products-and-Services/Health-and-Social-Care-Integration/ Living Well in Communities: Scoping and Design v1.0 13

http://www.isdscotland.org/Products-and-Services/Health-and-Social-Care-Integration/

Step 3 Taking a whole system view in planning design/redesign of new or different interventions and pathways, and stopping provision of non-value adding services.

Step 4 Implementation of change, measurement and assessment of change, and sharing learning with other partnerships and partners through existing and new networks.

The approach applied to each priority area is outlined in the following sections with more information in Appendix VIII to Appendix XII on pages 27 to 36.

4.3.2. Frailty and FallsFive partnerships have been identified to co-produce deep dive workshops using individual pathways for those considered to be frail. Living Well in Communities will provide improvement support to enable the partnerships to identify the issues with their existing pathways, and test and implement new interventions to re-design whole system pathways. Living Well in Communities will also seek to capture best practice in terms of frailty pathways, and develop a mechanism for spreading this learning.

4.3.3. High Resource IndividualsThe same five partnerships engaged through Frailty and Falls have been identified to co-produce deep dive workshops with a focus on high resource individuals using individually linked data that enables individual pathways to be produced. Living Well in Communities will provide improvement support to enable the partnerships to diagnose the issues with their existing pathways and test the re-design of whole system pathways. Living Well in Communities will also seek to capture best practice in terms of high resource individual pathways, and develop a mechanism for spreading this learning.

4.3.4. Anticipatory Care PlansLiving Well in Communities will facilitate partnerships to better understand individual pathways, including those for end of life, and as a result, identify opportunities for implementing anticipatory and advance care planning, that will enable people to self manage wherever possible, and increase the uptake and access to Key Information Summary.

4.3.5. Delayed DischargeLiving Well in Communities will offer time-limited support to partnerships to identify improvements, which the Expert Group has established will address underlying causes, but that have not yet been locally implemented and to test and implement innovative approaches to re-designing services. This will likely overlap with the focus on anticipatory care planning and frailty pathways, as a disproportionate number of people who are delayed being discharged are those aged 75 years and over.

4.3.6. HousingLiving Well in Communities will support a select number of partnerships to test innovative approaches to housing solutions that will contribute toward improving discharge pathways by providing quality improvement advice, particularly around evaluation, and facilitate the rapid sharing of knowledge.

4.3.7. Spreading learning and knowledgeCreation and use of knowledge and an evidence base are fundamental to improving care and services. There is growing literature on use of implementation science or knowledge translation to support improvement alongside the normative models of diffusion of innovation8. The inclusion of a knowledge broker should increase the pace at which knowledge is created and rapidly put into action. The knowledge broker will also help to identify knowledge

8 Fixen, D.L Living Well in Communities: Scoping and Design v1.0 14

gaps, provide support to overcome barriers to knowledge exchange, adaptation to context and translation into evidence.

4.3.8. Our approach to spreading learningThere is evidence describing the benefits of networking behaviours and use of networks to gain information and build social capital and the need for leaders to support people within their organisations to use them to leverage quality improvement and innovation9. The Quality Improvement Hub and The Integrated Care and Support Improvement Group are collaborating to bring together the Leading Quality Network and the Integrated Care and Support Improvement Network into a new improvement network for integrated care and support. The membership of this network will be those organisations, leaders and people working with communities to make changes across the health, social care, housing, education, third sector and independent sectors.

4.3.9. TimelineThe initial timeline for executing Living Well in Communities is outlined below in Figure 3. A specific timeline for each priority area will be developed following agreement on scope and resources.

9 Kotter Living Well in Communities: Scoping and Design v1.0 15

Figure 3 - Initial timeline for the execution of Living Well in Communities.

5. Summary and RecommendationsAn adapted 90 day process has been used to scope and design a portfolio of work to support the aim of:

“giving back at least 200,000 days to individuals families and communities that would otherwise have been spent in hospital.”.

It is recommended that the five priority areas of focus, improvement approaches and funding are approved for the Living Well in Communities portfolio of work, with the understanding that ongoing scoping, testing and analysis of data will continue to inform the tailoring of improvement support.

The process for approving the design and resources for LWiC is as follows:

Advice and approval of focus areas and theory of execution for LWiC by the NHSScotland Quality Improvement Hub

Approval of the resources required for LWiC by the Executive Team at Healthcare Improvement Scotland Sign-off of the design proposal by Scottish Government Health directorates

AppendicesAppendix I. List of Stakeholders

Academy of Royal Colleges

Alliance ScotlandLiving Well in Communities: Scoping and Design v1.0 16

Allied Health Professional Directors Group

Area Clinical Forum

British Geriatrics Society Scotland

Carers Organisation

Chief Officers

Convention of Scottish Local Authorities

Housing Regeneration Team, Scottish Government

Institute for Research and Innovation in Social Services

Integrated Care and Support Group

Joint Improvement Team Associates

Ko Awatea

Leading Quality Network

Local Authority Chief Executives

NHS Chief Executives

Overarching governance group, Scottish Government

Primary Care Leads

Quality Improvement Executive Leads

Royal College of General Practitioners

Royal Pharmaceutical Society Scotland

Scottish Ambulance Service

Scottish Association of Medical Directors

Scottish Care

Scottish Council for Voluntary Organisations

Scottish Executive Nurse Directors

Service Users and Families

Unscheduled Care Collaborative

Voluntary Action Scotland


Appendix II. Mapping Activity


Figure 4 - Evidence of mapping activity during scoping.

Appendix III. High Resource Individual Data

Figure 5 – Resource Usage by High Resource Individuals. Data relates to 2012/13 from Information Services Division, Integrated Resource Framework.


Population of Service Users

High resource individuals account for 2% of the Scottish population (103,715 individuals).

Usage of Hospital and Prescribing Resources

The high resource individuals (2% of population) use 50% of hospital and prescribing resource (£2.6 billion).

Usage of Inpatient Bed Days

The high resource individuals (2% of population) use 77% of inpatient bed days (4,932,731 bed days).

Appendix IV. End of Life Data

Figure 6 - Variation in hospitalisation in last six months of life.


Appendix V. Evidence on Reducing Beds from a Hospital SettingRadically different models of care have been proposed that could allow bed capacity to be moved out of the acute hospital setting in the longer term1. The King’s Fund drawing on five case studies in England, report a consensus among hospital leaders that managing the growing demand from an ageing population within existing bed capacity, presents the most realistic strategy for the short and medium term.1 However, there is currently an absence of rigorous evidence that in the longer term, new care models are effective in significantly reducing hospitals beds. A published case study of integrated care models developed in New Zealand, reports outcomes of effective control over bed occupancy level, but not substantial reductions in acute beds2.

The history of service transformation in mental health is seen to offer evidence of how the movement of care out-with of hospitals can result in bed reductions. However, a number of contextual factors have been identified that limit the generalisability of this evidence, in terms of the greater diversity of patients and conditions and the number of services that require redesign outside of mental health3. Retrospective, cross-sectional studies have been conducted on the impact of bed closures in Canada during the 90s, finding that access and quality of care were not adversely affected4 5. However, this evidence is considered highly dependent on the context of bed supply versus demand, in a review by the WHO Regional Office for Europe. The UK has one of the lowest numbers of beds per 1,000 people in Europe6 and is considered vulnerable to the risks associated with bed reduction, due to already high bed occupancy rates7.

The King’s Fund argue that the scale of opportunity for reducing hospital beds in the short term is limited in the UK context1. In Scotland, the occupancy rate for acute beds over the 9 quarters between March 2012 and March 2014, ranged from 83.5% to 85.6%8. Occupancy rates in excess of 85% have been found to greatly increase the risk of periodic bed crises and failures to admit acutely ill patients9. Furthermore, an acute hospital can expect regular bed shortages and periodic bed crises if average bed occupancy rises to 90% or more 9. Consequently, small reductions in beds would be expected to have adverse consequences for care outcomes, in the context of supply already being under pressure.

(References included in Appendix XIV on page 38)


Appendix VI. Evidence review

Risk of emergency admission and unplanned bed useThere is evidence of a number of drivers of unplanned bed use that could be targeted for intervention across community, primary and secondary care. The emergency admissions rates for Scotland are strongly related to patient age and deprivation. With the exception of the very young, rates rise with increasing age group, with patients aged over 75 having 7 times more emergency admissions per 100,000 than 16 to 24 year olds and 4 times more than 45 to 54 year olds1. A recent systematic review found that increasing age, lower socioeconomic status, and the presence of long term conditions and multi-morbidity are all significant patient risk factors for unplanned admission across different healthcare systems2.

Unplanned admissions are also known to be driven by ambulatory care sensitive conditions (ACSC), particularly for the over 75s3. Though there are varying definitions of what constitutes an ACSC condition they include the long-term conditions asthma, COPD, diabetes and congestive heart failure4. Unplanned admission of ACSC conditions are known to be avoidable through preventive and primary care intervention 5. Therefore, effective management and treatment of these conditions offers potential to reduce unplanned bed use. In addition, proximity to secondary care has been found to be a driver of unplanned admissions, with living in urban areas being associated with higher rates of emergency hospital admission than living in rural areas 6. However, it is not clear whether these rates are due to difficulty in accessing secondary care or because of improved primary and community care in rural areas7.

Avoidable emergency admissionEvidence of avoidable emergency admission has been clearly established in relation to ambulatory care sensitive conditions (ACSC), with rates being higher for those over 755. Though there are varying definitions of what constitutes an ACSC condition, emergency admissions for ACSC are associated with the long-term conditions asthma, COPD, diabetes and congestive heart failure6. ACSC conditions have been found to be avoidable through preventive and primary care intervention7. Therefore, effective management and treatment of these conditions offers potential to reduce emergency care use. However, it is also argued that admission is still required where the severity or complexity of the condition can only be treated optimally in acute care3.

Multi-morbidity and deprivation There is evidence from Scotland and the rest of the UK that people who live in areas of socio-economic deprivation have higher rates of emergency admissions, after adjusting for other risk factors 8 9. A particularly marked association between socio-economic deprivation and admissions in the Scottish population has been found for mental health conditions, including psychosis, Alzheimer’s and dementia in men and women and alcohol-related admissions in men9. There is evidence from cross-sectional study of Scottish patients that while physical-only multi-morbidity had a similar prevalence in the least and most deprived, mental only multi-morbidity was higher in the most deprived, particularly in younger age groups10. Mixed physical and mental multi-morbidity also found to be two to threefold higher in the most deprived compared with the least for the under 75s11 .

In contrast, a progressively lower ratio of non-emergency admissions with lower social class has been found in Scotland9. In Scotland, despite the gradient in healthcare need, the distribution of GPs remains flat across socio economic indices11. It has been suggested that the higher prevalence of multi-morbidity in deprived areas is responsible for increased demand on clinical encounters that reduces the ability of primary care provision to prevent emergency hospital admissions9 12 (Mercer et al). The mismatch of need and supply is known as the inverse care law13, which states that “the provision of good medical care tends to vary inversely with the need for it in the population served”.Living Well in Communities: Scoping and Design v1.0 22

Older people The evidence shows that as people grow older they become more at risk of unplanned hospital admission. Patients aged 80 and over accounted for almost all of the increase in bed days occupied by inpatients admitted as an emergency between 1981 and 2001 in Scotland14. Once in hospital, the elderly are then more likely to experience difficulties in being discharged, as 75% of all delayed discharge occupied beds are by those over 75 years old14. They are also likely to experience re-admission, with analysis of trends of showing multiple emergency admissions for those over 80 years old made a disproportionate contribution to the overall increase in the use of inpatient beds14.

It has been suggested that these increases may be due to a lack of informal care being available to the elderly, with social isolation known to be more common among this age group. There is evidence from a case-control study to support that social isolation in the form of the lack of social support from friends or family, is associated with a higher risk of emergency admissions for respiratory disease in older people 15. However, the presence of co-morbidity with long-term medical conditions (especially COPD) was of greater risk15.

The factors that drive emergency hospital admission for the elderly have also been suggested to drive readmission. A review exploring the variation of hospital bed use in the over 75s in England has found that areas with low bed use did not have high rates of readmission16. This was suggested as evidence that factors outside acute care were just as significant as any relating to inappropriate discharging of patients leading to shorter lengths of stay. These areas were suggested to have prioritised the needs of older people and have well-integrated services.

End of life care A high proportion of bed days are attributed to those within the last year of life. The cycle of admission and discharge in the last five years of life is a complex one that interfaces with the entire health and social care system across primary care, acute care, care at home, care homes and out of hours care. There is a well embedded approach to improving palliative and end of life care in Scottish Government healthcare policy that was initiated by the Living and dying well: a national action plan for palliative and end of life care in Scotland Living 17. Living and Dying Well: Building on Progress18 recognised that hospital admission may frequently represent the right care in the last five years of life, however improvements were required to ensure that advance/anticipatory care is provided appropriately and in accordance with patient’s wishes.

Particular emphasis has been placed in the policy literature on people’s preferences to die at home. The indications from a number of surveys is that the majority would prefer to be cared for and die at home 19 20. Furthermore, a recent systematic review found that most people prefer to die at home and this preference did not change as illness progress21. However, qualitative research has suggested expressed preferences to die at home are actually conditional due to the importance expressed by patients of limiting the burden of care for their families, and being made ‘comfortable’ at the end of life22.

In addition to the issue of location of care, equity of access has also been identified as a barrier to quality of care being received in the last years of life. The evidence of variation between partnerships in location of death, rather than being correlated with preferences being followed through for patients, has instead been suggested to reflect inequity of access. Furthermore, while there is a high level of provision of palliative care for cancer patients, a recent study has suggested that 80% of non-cancer patients are not being identified by primary care as requiring palliative care, despite this being of benefit to them23. This is supported by recent longitudinal qualitative research that found that the rapid throughput of patients in hospital and time pressures in primary care were both hindering identification of palliative care needs in both primary and secondary care24. Early identification has been put forward as key to ensuring that patients are able to enter appropriate conversations to make decisions about their care which is a key priority area for action from Living and Dying Well: Building on Progress18.Living Well in Communities: Scoping and Design v1.0 23

A further priority area for action is advance/anticipatory care planning (ACP). There are a number of barriers and challenges identified as limiting the anticipatory quality of end of life care. Primary and secondary care professionals report difficulty in identifying patients entering the last year of their lives due to prognostic uncertainties, relying on significant events or marked deterioration in the patient's condition as determining factors19. In addition, a minority of patients have been found to be open in their awareness and willingness to discuss and even initiate ACP discussion20. Consequently, ACP is likely to be reactive and to happen late.

Evidence of the effectiveness of interventions to reduce unplanned bed useA complex relationship of community and primary care quality alongside factors of informal care predicting unscheduled acute care has been described in the published literature. A recent Kings Fund review 21 found that evidence of effective interventions is mixed, with more robust evidence being required to support the change of services. However, similar to the findings of the evidence review in relation to shifting the balance of care in Scotland22, a positive effect on unplanned admissions and readmissions was found to support the following:

Reducing admissions:

Continuity of care from being able to see the same family GP

Integration of primary and secondary care

Self-management in patients with COPD and asthma

Tele-monitoring in heart-failure

Assertive case management in mental health

Senior clinician review in A&E

Multidisciplinary interventions

Reducing re-admissions:

Structured discharge planning

Personalised health care programmes

(Reference included in Appendix XIV on page 39)


Appendix VII. Contributing programmes

Delivering Outpatient Integration TogetherThe aim of the programme is that all people are seen in the right place, at the right time, by the right person with the right information. The programme’s work streams include managing flow and implementing new technology enabled, integrated outpatient services for people with long-term conditions. The programme has been co-produced with Board outpatient services leads, clinicians, patients and public representatives with QuEST and Access Support Team colleagues, from the Scottish Government.

Technology Enabled CareThe aim of the programme is to increase the number of people using technology to enable delivery of health and social care at home. The objectives of the programme are to:

Accelerate spread across Scotland of a minimum of three effective innovations in technology enabled care: home monitoring, video technology and apps

Increase the capacity and capability to deliver technology enabled care in all NHS Boards, integration authorities and their partners

Improve sustainability of technology enabled care within redesigned pathways

Unscheduled careUnscheduled Care is a key priority for Scottish Government, with all NHS Boards aiming to sustainably achieve 95% of all patients attending A&E to be seen, treated and discharged or admitted within 4 hours. A collaborative has been established which includes Scottish Government and local unscheduled care performance improvement teams in each hospital.

Acute flowThe Whole System Patient Flow Improvement Programme will adopt a whole systems approach to patient flow designed to ensure patients receive the right care at the right time in the right place by the right team every time and will promote the bringing together of both elective and unscheduled work streams to supporting a whole system approach.

House of CareHouse of Care is a model for a proactive and co-ordinated system of care and support for people with long-term conditions. The model encourages people with long-term conditions to play an active part in determining their own care and support needs by co-producing a single holistic care plan with their care co-ordinator (often GP or nurse). The model is being piloted in three areas across Scotland.

Primary Care AccessPrimary Care Access includes: a review of out-of-hours primary care services to address issues such as recruitment and retention of GPs, staff availability, consistency of service and the public’s expectations, and, the General Medical Services Contract (Quality and Productivity Indicator Q0002): Undertaking a review of access and preparing Practice Access Action Reports: Three steps to review access and prioritise improvements in patient flow.

Palliative careThe commissioning and planning of most palliative and end of life care in hospital and the community will now be the responsibility of the new health and social care partnerships. A National Advisory Group has been established


and wide engagement is underway across Scotland to inform the development of a Palliative and End of Life Care Strategic Framework for Action.

DementiaThe Focus on Dementia national improvement programme is a partnership between Scottish Government, Joint Improvement Team, Alzheimer Scotland, and QuEST to support the delivery of post-diagnostic support, to test the Alzheimer Scotland ‘8 Pillars’ model for community based support, and to support improvement in the care of individuals with dementia in acute hospitals.


Appendix VIII. Frailty and fallsContextBackground The ‘Think Frailty’ improvement programme states, that improving outcomes for older people

remains a national priority in Scotland. Growing numbers of frail older people are admitted to hospital as an emergency and some of those admitted will deteriorate further or experience a delay in returning home, or are assessed, often prematurely, by hospital clinicians as unable to return home.

The Prevention and Management of Falls in the Community Framework for Action states that, with health and social care services and their partners working to address the challenge of an ageing population and rising demands on public services, falls among older people are a major and growing concern. The National Falls programme aims for every health and social care partnership to have a local integrated falls and fracture prevention and management pathway in operation by 2016.

National Data - Analysis of resource use in the year 2012/13 identified that 36,632 of the highest resource users in Scotland that were aged 75 years and over accounted for 2.3m inpatient bed days

- 75% of all beds occupied through delayed discharge are by those aged 75 years and over

- The number of emergency bed days used by over 75s has decreased, however the number of admissions has increased from 135,907 in 2009/10 to 148,937 in 2013/14

− Unscheduled care costs NHSScotland £1.5bn per year− Economic evaluation estimated that falls alone cost NHSScotland £471m per year− Falls account for 390,000 emergency bed days a year− A third of over 65s experience a fall each year− Half of those over 80 years old experience a fall each year

Related Health & Wellbeing outcomes

1 People are able to look after and improve their own health and wellbeing and live in good health for longer.

2 People, including those with disabilities or long term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community.

3 People who use health and social care services have positive experiences of those services, and have their dignity respected.

4 Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services.

7 People who use health and social care services are safe from harm.

Evidence for improvement

Analysis of data and evidence has shown that with increasing age comes an increased risk of episodic emergency hospital admission. People aged 75 years and over in Scotland are 7 times more likely to experience an unplanned admission per 1,000 of the population compared to those aged between 16-24, and those aged 80 years and over have accounted for almost all of the increase in emergency bed days between 1981 and 2001 in Scotland.

Reducing the amount of time that older people spend in a hospital setting is already a focus of the Scottish Government, which developed a HEAT target to reduce the rate of emergency inpatient bed days for people aged 75 and over per 1,000 population.

Examples of effective falls management and prevention range from increasing awareness of falls prevention activities for those that work with older people, identifying individuals at risk,


and developing linked pathways to ensure that older people are not inappropriately taken to Accident & Emergency. Evidence suggests that interventions to reduce the likelihood of the frail elderly requiring emergency hospital attention, or once in hospital to reduce length of stay, are similarly focused on clinical pathways, exercise interventions and multidisciplinary teams to ensure early and effective discharge once in hospital.

There is strong national and international evidence on the role of a multi-disciplinary team to navigate patients to the right care, such as incidences of falls which are the most frequent single ‘diagnosis’ presenting to the Scottish Ambulance Service in the over 65 cohort. Evidence suggests that integrated urgent care pathways for falls and frailty that focus on triage, assessment, and management, increase the likelihood of people remaining in the community. NHS Borders trialed a pilot study of professional to professional decision support, whereby attending SAS crews were provided with clinical support by a GP when it was felt that conveying the person to hospital may not be required. The pilot was positively evaluated with only 9% of patients in the initial pilot phase being transferred to the emergency department (a 5% reduction in overall attendances at the ED via ambulance)10.

AimsObjectives of Living Well in Communities

The aim of this activity will be to reduce the likelihood of the frail elderly experiencing an unplanned hospital admission and reduce total emergency bed days. In doing so, we will hope to achieve an increase in the amount of time that the frail elderly spend living in a community setting.Measureable aims will be set at a partnership level following deep dives.

Scope of workHealth and Social Care partnerships

Argyll & Bute, Fife, Glasgow City, North Lanarkshire and South Lanarkshire.

Activities Support partnerships to: Undertake a diagnostic of their current frailty pathways using HRI data and local data Identify areas for system wide improvement Establish a measurement and outcomes framework to identify improvements in

systems, personal and clinical outcomes, and to support the national Health and Wellbeing outcomes and indicators

Design, test and spread new system wide pathways of care attuned to the needs of frail older people.

National Programme Support to: Build the business case for quality by gathering further economic evidence Disseminate learning rapidly across the system through development, testing and

cascade of web based tools and resources that help other partnerships adopt the improvements, and connect with an international community of practice through Scotland’s partnership with the International Foundation for Integrated Care

Provide national improvement support to build capacity and capability for quality improvement in practitioners and managers working in local integrated teams and across the spectrum of care settings.

Additional considerationsThere is likely to be an overlap between the areas of frailty and high resource individuals.

The work on Frailty and Falls will interface with, and draw on support from, a number of existing programmes and activities of other organisations, including:

10 Making the right call for a fall – Scottish Ambulance ServiceLiving Well in Communities: Scoping and Design v1.0 28

- The Unscheduled Care Collaborative, particularly in relation to essential action 6, which aims to ensure that where possible people are cared for in their own home

- Information Services Division’s Health and Social Care Data Integration and Intelligence Project (HSCDIIP), which has been designed to assist Health and Social Care Partnerships in understanding how their population interacts with services

− Scottish Government, Health and Social Care Integration Directorate in relation to their work on integration and support for Integrated Joint Boards and strategic planning

- Local Intelligence Support Team (part of ISD) which will provide data analyst resource to partnerships to support them in using data to inform service design

- Older People in Acute Care Improvement Programme

Living Well in Communities will fund the following posts specific to Frailty and Falls:- Clinical Advisor (0.2 WTE)


Appendix IX. High Resource IndividualsContextBackground Strategic planning and locality planning is an important part of the new integration Act. To

provide partnerships with information for planning (and performance reporting) the Scottish Government commissioned Information Services Division to develop a data base for health and social care.

Once complete, the database will contain inked individual level health and social care activity and costs which will identify an individual’s use of health and social care services across time.The database currently includes hospital and community prescribing information for Scotland, and shows that a very small proportion of the population uses half of the total hospital and prescribing budget. There is potential for partnerships to gain a better understanding of how resources are used, and services interacted with, in their area, to better align services and improve pathways

Data - 2% of the population in Scotland used 50% of the hospital and community prescribing

resource in 2012/13

- This translates to 103,715 people using £2.6bn of the hospital and prescribing

resources

- The 2% of the population were responsible for 77% of all inpatient bed days

- This translates to 103,715 people using approximately 4.9m bed days (4.4m of these

through unplanned admissions)






5 Health and social care services contribute to reducing health inequalities.

9 Resources are used effectively and efficiently in the provision of health and social care services.


The number of emergency admissions and emergency bed days are important indicators for measuring the effectiveness of integrated care. An analysis of High Resources Individuals should provide an understanding of the most common pathways for unplanned and multiple admissions and identify areas where action could be taken to prevent future avoidable admissions. Even a modest reduction in High Resource Individuals admissions could make a significant reduction in overall unplanned bed days; with a 5% reduction of High Resource Individual unplanned bed days equating to 220,000 bed days. It is likely that a proportion of High Resource Individuals will include patients on a frailty pathway.

The Institute for Healthcare Improvement recently published a paper that identifies the key components that must be executed when segmenting population groups in a bid to achieve the Triple Aim, however this does not include assertions about which interventions to deploy.



- Develop and understand the current pathways, bed days and social resource use by individuals

- Identify gaps in data and information in the current system- Identify priority areas for system wide improvement- Identify areas for co-production, synergy and support to reduce bed days used by high

resource individuals.


Argyll & Bute, Fife, Glasgow, North Lanarkshire and South Lanarkshire.

Activities The diagnostic exercise will begin with a deep dive of data relating to high resource individual with the focus tailored to the individual needs and local challenges of each partnership. The data deep dive will be delivered with support from the Local Intelligence Support Team (LIST), part of Information Services Division (ISD). The Living Well in Communities team will bring together local service leads from the partnership to facilitate them to draw useful insight from the data that can be used to prioritise areas for improvement. The learning from the diagnosis will be used to test improvements to specific pathways with the overall aim of improving the quality of care for high resource individuals, reducing the number of individuals becoming high resource individuals, reducing the number of unplanned hospital admissions and reducing the total number of emergency bed days.

Additional considerationsDue to the overlapping nature of High Resource Individuals with Frailty, learning from the deep dive diagnostic exercises is likely to support the Frailty priority area within Living Well in Communities.

The work on High Resource Individuals will interface with, and draw on support from, a number of existing programmes and activities of other organisations, including:

- The Unscheduled Care Collaborative, particularly in relation to essential action 6, which aims to ensure that where possible people are cared for in their own home



- Local Intelligence Support Team (part of ISD) which will provide data analyst resource to partnerships to support them in using data to inform service design


Appendix X. Anticipatory Care PlanningContextBackground The likelihood of living with multiple chronic or complex conditions increases with age. It is

essential that a proactive and forward thinking approach is adopted and relevant steps are put in place to ensure that models of care are designed to meet the many needs of individuals. Anticipatory Care Planning facilitates a whole-systems approach for people living with long-term conditions, ensuring that person-centred care and personal outcomes are achieved.Anticipatory Care Planning links to end of life care, as they both have a focus on how individuals and care providers can better plan to improve an individual’s health and wellbeing. By discussing together their personal goals and wishes, an individual’s decisions can be respected in the event of a gradual or sudden decline. Anticipatory Care Plans and poly-pharmacy reviews are included as a quality and productivity indicator in the General Medical Services Quality Outcomes Framework in Scotland.

Data - More than 55,000 people die each year in Scotland, with over half of the deaths taking place in hospital

- Of those that die, 40,000 have palliative care needs, but only 12,000 are on the QOF register for palliative care

- In the year 2012/13 82% of people within the final six months of life experienced a hospital admission

- In the same year 1.2m bed days were used by those within the final six months of life






6 People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative Impact of their caring role on their own health and well-being.

8 People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide.



A study was undertaken in 2010 to evaluate the impact of introducing Anticipatory Care Plans (ACP) for a cohort of people from a general practice in Nairn, Scotland, that were considered to be at high risk of experiencing a hospital admission (identified using the Scottish Patients at Risk of Readmission and Admission tool). A group of individuals with a similar SPARRA score were also identified but ACPs not introduced to compare the two sets of results. When comparing the 12 months preceding the introduction of ACPs to the 12 months following (for those that were still alive in the second 12 months), the group of individuals for which ACPs were introduced saw a 52% reduction in the number of days spent in hospital. The study also found that for those who died during the second 12 month period, individuals with an ACP were more likely to be able to die at home11.


A similar study of Anticipatory Care Plans was undertaken in a care home in NHS Lanarkshire in 2009. Evaluation of the study found that when comparing the six month periods prior to and following implementation of the ACPs, there was a 34% reduction in the number of inpatient admissions and over 50% reduction in the number of hospital bed days12.


The aim of this activity will be to achieve person-centred care and personal outcomes for people with long-term conditions, through an increase in the number of Anticipatory Care Plans being used across Scotland, an increase in the percentage of the final six months of life being spent in the community, and a reduction in the rate of emergency admissions.


The work is expected to be national but the specific partnerships have yet to be identified.

Activities Living Well in Communities will support partnerships to implement elements of the Anticipatory Care Plannning action plan; which aims to:

- Embed ACP as a model to deliver proactive, intensive collaborative case management in every locality

- Work with hospital and emergency services to increase access to Key Information Summary

- Work with national carer organisations to ensure appropriate carer support and involvement in ACP

Living Well in Communities will specifically focus on implementing the use of Anticipatory Care Planning through work with partnerships to understand whole system pathways and prevent unnecessary hospital admissions.

Additional considerationsA focus on ACP is likely to have an impact on end of life care. The approach used as part of Living Well in Communities will complement the priorities identified in the soon to be developed Palliative and End of Life Care Strategic Framework for Action.

Living Well in Communities will fund the following posts specific to the focus area of Anticipatory Care Planning:

- Associate Improvement Advisor (1 WTE)- National Clinical Lead, Nursing/AHP (0.4 WTE)- National Clinical Lead, GP (0.2 WTE)

The work on Anticipatory Care Planning will interface with, and draw support from, the national Anticipatory Care Planning Task & Finish group.

11 Anticipatory Care Planning and Integration: a primary care pilot study aimed at reducing unplanned hospitalisation: British Journal of General Practice, February 201212 NHS Lanarkshire, Long Term Conditions Team, Anticipatory Care Plans in Lanarkshire Evaluation, April 2010Living Well in Communities: Scoping and Design v1.0 33

Appendix XI. Delayed DischargeContextBackground The Scottish Government is committed to significantly reducing the number of people in

Scotland who are delayed being discharged from hospital.The targets relating to delayed discharge have recently been refreshed, with an expectation that people are discharged within 72 hours of being declared clinical ready.Partnerships are currently offered practical support to improve discharge pathways, deliver better outcomes for people and reduce the bed days associated with delays.A Discharge Taskforce was established in 2014 to advise on the use of national funding and to agree short and medium term priorities for support to improve discharge.The Joint Improvement Team has set out ten actions to transform discharge, which includes scaling up coordinated and anticipatory care, building capacity for care and support at home and screening and assessing for frailty.

Data - The number of bed days occupied by delayed discharge patients has risen from 491,721 in 2012/13 to 623,438 in 2013/15

- On average, those aged 75 years and over account for 75% of delayed discharge occupied hospital bed days

- The most common reasons for delayed discharge are due to awaiting a place in a care home, waiting to go home, and awaiting a community care assessment







An expert group for Delayed Discharge noted a number of key success factors in reducing delays in hospital which include: a ‘whole system approach’ that offers alternatives to hospital admission, frailty screening to prompt early specialist geriatric assessment, more coordinated rehabilitation encompassing hospital, community and care home based services, and early discharge by a named person who can coordinate the ‘patient journey’ including engaging with ‘housing’. In addition to addressing pathway issues, success can be achieved by adoption and communication of a culture of ‘Home First’ as a default position, whereby patients are returned to the home they were admitted from, providing it is safe to do so, and only explore alternatives if this is not possible13. http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets/Delayed-Discharge/Expert-group-report

Evidence of integrated approaches to improving discharge pathways include South Warwickshire NHS Foundation Trust, which worked with community care partners and social care to develop the Discharge to Assess (D2A) programme that seeks to integrate acute and post-acute care. After admission, patients undergo early, comprehensive geriatric assessment, visible to and trusted by all organisations involved in the pathway. Individuals are then placed on one of three pathways, depending on the complexity of their needs. A care coordinator ensures that care packages are in place, but just as importantly, has early conversations with the patient and their relatives to help them understand how important getting out of hospital

13 Home First, Ten Actions to Transform Discharge – Joint Improvement TeamLiving Well in Communities: Scoping and Design v1.0 34

http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets/Delayed-Discharge/Expert-group-report

http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets/Delayed-Discharge/Expert-group-report

is for the patient’s health and the options for support outside hospital. The programme reduced average length of stay by 33% whilst also reducing readmissions to acute by 3%14.


The aim of the programme is to see a reduction in the number of bed days occupied by delayed discharge patients.


The number of partnerships will be determined through a programme of planned strategic commissioning and performance discussions and requests for support from partnerships themselves.

Activities Living Well in Communities will offer time-limited support to partnerships to enable them to identify areas for improvement and to test and implement innovative approaches to re-designing pathways.

Additional considerationsThe work on Delayed Discharge will interface with, and draw on support from, a number of existing programmes and activities of other organisations, including:



− Similarly, the Local Intelligence Support Team (part of ISD) which will provide data analyst resource to partnerships to support them in using data to inform service design

− The Tailored and Responsive Support Team (Healthcare Improvement Scotland), which will support partnerships with improvement work; some of which will relate to delayed discharge

14 Acute hospitals and integrated care. From hospitals to health systems – The King’s FundLiving Well in Communities: Scoping and Design v1.0 35

Appendix XII. HousingContextBackground The Strategic Commissioning Plans Guidance (December 2014) states that, while the housing

sector already makes a very significant contribution to national outcomes on health and social well-being, the integration of adult health and social care will present opportunities to strengthen the connections between housing and health and social care to support the shift to prevention.

Nevertheless, there remain challenges and constraints which will make it harder to realise the potential benefits, such as the challenge that most aspects of housing services will remain out with the scope of partnerships.

An action plan has been developed which urges improvements in the day to day processes for coordinating the care for people between health and social care, housing organisations and those in receipt of care. Housing is generally thought to make a contribution to ‘downstream’ discharge of patients from hospital but it also has the potential to contribute to ‘upstream’ prevention of hospitalisation by helping people live at home for longer.

There is potential for partnerships to gain a better understanding of how resources are used, and services interacted with, in their area, to better align services and improve pathways.

Data - 51,720 sheltered houses

- 27,093 houses fitted with a community alarm

- 2,131 houses adapted for wheelchair use






Reducing delayed discharge and avoiding unnecessary admission to hospital are key national priorities with a range of different initiatives being taken forward. The importance of ‘fit for purpose’ housing, and the wider contribution that housing organisations can make, has gained greater recognition over the past year, with a number of initiatives being developed as part of the Discharge Task Force and the Joint Housing Delivery Plan.

The Scottish Government has put a great deal of emphasis on the inclusion of housing representatives in Strategic Planning Groups at Partnership and locality level, and this is generating considerable interest in how to ensure that housing can make a full contribution to the national Health & Wellbeing outcomes. Housing has a role to play in providing a homely setting for patients to be discharged as well as providing support in the community to prevent avoidable admissions.

A review of housing projects and practice focused on assisting the NHS and social care to alleviate potential delayed discharges has been undertaken by the Joint Improvement Team. They found a number of projects across the UK with potential for reducing the number of bed days in hospital. They are:

- The provision of respite or step up/step down care- The establishment of housing options/advice/broker services in acute hospital settings


to co-ordinate housing service activity assisting people to return home- The establishment of direct connections between GP practices and local housing

providers in communities to advance models of ‘social prescribing’ and care co-ordination

- A re-focus on the need and supply of specialist supported accommodation and the fit within the wider residential and acute care settings to meet a range of needs (i.e. older people, mental health, addictions)

- Localised projects on improving intelligence between the link between hospital admissions and discharges and the local social housing tenant population (this could be extended to home ownership sector as well) and/or neighbourhoods where specific health inequalities issues exist.


The aim of this priority area will be to support the implementation of the Joint Improvement Team’s (JIT) Housing programme; to:

- Test step-up/step-down accommodation in sheltered housing to reduce discharge delays from hospital for housing related reasons

- Test an approach to rapid review of delayed discharge cases or those likely to be delayed in hospital

- Develop housing options with care for those with complex needs who are effectively living in hospital with no date of discharge

- Test approaches for high resource individuals who are homeless or are unable to return to their current home

- Develop housing options advice as part of the discharge assessment.


The number of partnerships will be determined through a programme of planned strategic commissioning and performance discussions and requests for support from partnerships themselves.

Activities Living Well in Communities will specifically focus on providing time-limited quality improvement advice and support to existing JIT-led improvement activity, particularly for the evaluation of approaches designed to reduce the number of hospital bed days. Support will be provided on a request-basis to the JIT Housing programme and the group of partnerships they are working with for housing diagnostic and testing activity. Living Well in Communities will also support the rapid sharing of learning from Housing activity.

Additional considerationsHousing potentially has an impact upstream and downstream of traditional care pathways, which may result in learning from Housing informing Frailty, High Resource Individuals, Anticipatory Care Planning and Delayed Discharge focus areas. Living Well in Communities will actively share housing knowledge between the different focus areas within Living Well in Communities to ensure housing knowledge is widely available and used to support the delivery of the 2020 vision.

Living Well in Communities will provide funding of £128,000 in the year 2015/16 to test a range of ‘Housing’ activities led by the Joint Improvement Team.The work on Housing will interface with, and draw on support from, existing resource within JIT and the Housing and Regeneration Team within the Scottish Government.


Appendix XIII. Health and Social Care Integrations Indicators

Table 2 - Health and Social Care Integration Indicators.

Indicator Definition and source Ambition Link to Living Well in Communities

Integration person/carer outcome indicators

1. Percentage of adults able to look after their health very well (Range 51-64%)2. Percentage of adults supported at home who agree that they are supported to live as independently as possible (Range 68-90%)3. Percentage of adults supported at home who agree that they had a say in how their help, care or support was provided (Range 73-90%)4. Percentage of adults supported at home who agree that their health and care services seemed to be well co-ordinated (Range 64-89%)5. Percentage of adults receiving any care or support who rate it as excellent or good (Range 74-92%)6. Percentage of people with positive experience of the care provided by their GP Practice (Range 79-97%)7. Percentage of adults supported at home who agree that their services andsupport had an impact in improving or maintaining their quality of life (Range 73-98%).

http://www.gov.scot/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/GPAccessStandard

An increase in the percentage for each survey question.

All

Emergency admission rate Rate of emergency admissions/100,000 population for adults http://www.isdscotland.org/Health-Topics/Hospital-Care/Inpatient-and-Day-Case-Activity/

A reduction in the emergency admission rate to manage future demand.

Anticipatory care planning Safe and suitable housing Frailty and falls Mental health options Improved Partnership



working Age and deprivation -

inequalities

Emergency bed day rate Rate of emergency bed days/ 100,000 population for adults A reduction in the emergency bed day rate to manage future demand.

Delayed discharge - step down care, care home optionsIn patient flow

Readmission to hospital within 28 days

(To be defined. Number of readmissions to acute hospital within 28 days/1000 population)

A reduction in the readmission rate.

Anticipatory care planning(Primary care options and co-ordination of care)

Proportion of last six months spent at home or in a community setting

http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/End-of-Life-Care/

An increase in the proportion of last six months of life spent at home or in a community setting.

Anticipatory care planningEnd of life and palliative care

Falls rate per 1000 population in aged 65+

(To be defined) A reduction in the falls rate. Frailty and falls

Percentage of adults with intensive care needs receiving care at home

The number of adults (18+) receiving personal care at home or direct payments for personal care, as a percentage of the total number of adults needing care.

http://www.gov.scot/Topics/Statistics/Browse/Health/Data/CommunityCareOutcomes

An increase in the percentage.

Delayed discharge - care at home and home careSafe and suitable housingHigh resource users

Number of days people spend in hospital when they are ready to be discharged,

The number of bed days due to delayed discharge that have been recorded for peopleresident within the Local Authority area, per 1,000 population in the area.

A reduction in the rate. Delayed discharge



per 1,000 population http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-Discharges/

Percentage of health and care resource spent on hospital stays where thepatient was admitted in an emergency

(To be defined) A reduction in the percentage of resource spent on hospital stays.

Anticipatory careDelayed discharge - Intermediate careHigh resource individuals

Percentage of people admitted to hospital from home during the year, who aredischarged to a care home

(To be defined) A reduction in the percentage of people that are discharged to a care home.

Delayed discharge - Intermediate care, re-ablement

Percentage of people who are discharged from hospital within 72 hours of beingready

(To be defined) An increase in the percentage of people who are discharged within 72 hours. This will need to be balanced by readmissions data.

Delayed discharge

Expenditure on end of life care

(To be defined) End of life and palliative careHigh resource individuals

Dementia To deliver expected rates of dementia diagnosis and by 2015/16, all people newly diagnosed with dementia will have a minimum of a year’s worth of post-

Dementia



diagnostic support coordinated by a link worker, including the building of a person-centred support plan

Drug and alcohol waiting times

90% of clients will wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery

High resource users

GP Access Provide 48 hour access or advance booking to an appropriate member of the GP Practice Team

http://www.gov.scot/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/GPAccessStandard

Primary care options and co-ordination of care


Appendix XIV. References

Reference list for main body of reportBartel, C.A. and Garud, R. (2009) The role of narratives in sustaining organisational innovation. Organization Science, Vol 20 (1), pp. 107-117.

Fixen, D.L., Naoom, S.F., Blase, K.A., Friedman, R.M. and Wallace, F. (2005) Implementation Research: A Synthesis of the Literature. Florida: University of South Florida, Louis de al parte Florida Mental Health Institute, The National Implementation Research Network.

Bevan, H. and Fairman, S. (2014) The new era of thinking and practice in change and transformation: A call to action for leaders of health and care. NHS Improving Quality. www.nhsiq.nhs.uk

Bevan, H., Plesk, P. and Winstanley, L. (2011) Leading Large Scale Change: A Practical Guide. Coventry: NHS Institute for Innovation and Improvement. www.institute.nhs.uk/academy

Greenhalgh T, Robert G, Bate P, MacFarlane F, Kyriakidou O (2005). Diffusion of Innovations in Health Service Organisations. Oxford: Blackwell Publishing Ltd.

Ibanez de Opacua, A. (2013) Guide on spread and sustainability. Healthcare Improvement Scotland.

Kaplan, H.C., Brady, P.W., Dritz, M.C., Hooper, D. K., Linam, W.M., Froehle, C.M. and Margolis, P. (2011) The influence of context in quality improvement success in health care: A systematic review of literature. The Millbank Quarterly, Vol. 88 (4), pp.500-559.

Ovretveit, J. (2011) Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Quality Safety, Vol. 20 (S1) pp. 18-23 http://qualitysafety.bmj.com/site/about/unlocked.xhtml

Taylor, M.J., McNicholas, C. Nicolay, C. et al. (2013) Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality Safety, Vol 0, pp.-9.

The Centre for Theory of Change (2013). http://www.theoryofchange.org/what-is-theory-of-change/ [Accessed 050615]

The Scottish Government (2014) One Scotland – Programme for Government. http://www.gov.scot/About/Performance/programme-for-government

The Scottish Government (December 2011) National Outcomes - Public Services.

http://www.gov.scot/About/Performance/scotPerforms/outcome/pubServ

The Scottish Government (February 2015) National health and wellbeing outcomes. http://www.gov.scot/Resource/0047/00470219.pdf

Welbourne, D., Warwick, R. Carnall, C. and Fathers, D. (2012) Leadership of Whole Systems. The King’s Fund.


http://www.gov.scot/About/Performance/scotPerforms/outcome/pubServ

http://www.gov.scot/About/Performance/programme-for-government

http://www.theoryofchange.org/what-is-theory-of-change/

http://www.institute.nhs.uk/academy

The Scottish Government The prevention and management of falls in the community. A framework for action for Scotland 2014/2016

Whittington, J.W., Nolan, K., Lewis, N., Torres, T. (2015) Pursuing the Triple Aim: The First 7 years. Institute for Healthcare Improvement

Reducing hospital bed use in the frail elderly – report for Scottish Association of Medical Directors

Baker, A., Leak, P., Ritchie, Lewis.D., Lee, Amanda.J., Fielding, S. (2012) Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalization.

NHS Lanarkshire (2010) Anticipatory care plans in Lanarkshire – Evaluation

Joint Improvement Team. Home First – Ten Actions to Transform Discharge

Reference list for Appendix V – Evidence on reducing beds from a hospital setting1. Naylor, C Alderwick, H Honeyman, M. Acute hospitals and integrated care: From hospitals to health systems. The King’s Fund; 2015 [cited 2015 July 03;] Available from: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/acute-hospitals-and-integrated-care-march-2015.pdf

2. Timmins N, Ham C (2013). The quest for integrated health and social care. A case study in Canterbury, New Zealand. The King’s Fund; 2013 [cited 2015 July 03]; Available from: www.kingsfund.org.uk/ publications/quest-integrated-health-and-social-care

3. Gilburt H, Peck E, Ashton B, Edwards N, Naylor C (2014). Service transformation: lessons from mental health. The King’s Fund; 2014 [cited 2015 July 03]; Available at: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/service-transformation-lessons-mental-health-4-feb-2014.pdf

4. Roos NP, Shapiro E. Using the information system to assess change: the impact of downsizing the acute sector. Medical Care; 1995; 33(12 Suppl.):DS109–DS126.

5. Brownell MD, Roos NP, Burchill C. Monitoring the impact of hospital downsizing on access to care and quality of care. Medical Care; 1999; 37(6 Suppl.):JS135–JS150

6. OECD. OECD health statistics 2014: how does the United Kingdom compare? [online]. 2014 [cited 2015 July 03]; Available from: www.oecd.org/unitedkingdom/Briefing-Note-UNITED-KINGDOM-2014.pdf

7. McKee M. What are the lessons learnt by countries that have had dramatic reductions of their hospital bed capacity? WHO Regional Office for Europe (Health Evidence Network report); 2003 [cited 2015 July 03]; Available from: http://www.euro.who.int/__data/assets/pdf_file/0004/74713/E82973.PDF


8. ISD Scotland. Acute Hospital Activity and NHS Beds Information Quarter ending. 2014 [cited 2015 July 03]; Available from: http://www.isdscotland.org/Health-Topics/Hospital-Care/Publications/2014-06-24/2014-06-24-AcuteActivity-Report.pdf

9. Bagust A, Place M, Posnett J W. Dynamics of bed use in accommodating emergency admissions: stochastic simulation model. British Medical Journal; 1999; 319:155

Reference list for Appendix VI –Hospital bed use and end of life care1. ISD Scotland. Emergency Admissions [online]. 2014 [cited 2015 Jun 01]; Available from: http://www.isdscotland.org/Health-Topics/Quality-Measurement-Framework/Emergency-Admissions/

2. Huntley A, Lasserson D, Wye L, Morris, R, Checkland, K, England H, Salisbury C, Purdy S. Which features of primary care affect unscheduled secondary care use? A systematic review. BMJ Open 2014;4(5)

3. Purdy S. Avoiding hospital admissions. What does the research evidence say? The King’s Fund; 2010 [cited 2015 Jun 01]; Available from: http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

4. O’Donnell C. Variation in GP referral rates: what can we learn from the literature? Family Practice 2000;17:462-71

5. The King’s Fund. Data briefing: Emergency hospital admissions for ambulatory care-sensitive conditions. 2012 [Cited 2015 Jun 01]; Available from: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/data-briefing-emergency-hospital-admissions-for-ambulatory-care-sensitive-conditions-apr-2012.pdf

6. Purdy S, Griffin T, Salisbury C et al. Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians. Public Health 2009;123:169-73

7. Purdy S, Griffin T, Salisbury C, Sharp D. Emergency admissions for chest pain and coronary heart disease: a cross-sectional study of general practice, population and hospital factors in England. Public Health 2010;125:46-54

8. Majeed A, Bardsley M, Morgan D, O’Sullivan C, Bindman A. Cross-sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission. British Medical Journal 2000; 321(7268):1057–60

9. McCartney G, Hart C, and Watt, G. How can socioeconomic inequalities in hospital admissions be explained? A cohort study. BMJ Open 2013;3(8)


http://eprints.gla.ac.uk/view/journal_volume/BMJ_Open.html

http://eprints.gla.ac.uk/view/author/5386.html

http://eprints.gla.ac.uk/view/author/3424.html

http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

http://www.isdscotland.org/Health-Topics/Quality-Measurement-Framework/Emergency-Admissions/

10. McLean G, McLean G, Gunn J, Wyke S, Guthrie B, Watt GC, Blane DN, et al. The influence of socioeconomic deprivation on multi-morbidity at different ages: a cross-sectional study. British Journal of General Practice 2014;64(624)

11. Mackay D, Sutton M, Watt G. Deprivation and volunteering by general practices: cross sectional analysis of a national primary care system. BMJ 2005;331:1449–51

12. Mercer SW, Watt GCM. The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland. Annals of Family Medicine 2007; 5(6):503–10

13. Watt G. The inverse care law today. Lancet 2002;360(9328):252–253

14. Kendrick S, Conway M. Increasing emergency admissions among older people in Scotland: a whole system account. 2003 [Cited 2015 Jun 01]; Available from: http://showcc.nhsscotland.com/isd/files/whole_system%20_wp1_text.pdf

15. Jordan RE, Hawker JI, Ayres JG, et al. Effect of social factors on winter hospital admission for respiratory disease: a case–control study of older people in the UK. The British Journal of General Practice 2008;58(551):e1-e9

16. Imison C, Poteliakhoff E, Thompson J. Older people and emergency bed use. Exploring variation. 2012 [cited 2015 Jun 01]; Available from: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/older-people-and-emergency-bed-use-aug-2012.pdf

17. Audit Scotland. Review of community health partnerships. 2011 [cited 2015 Jun 01]; Available from: http://www.audit-scotland.gov.uk/docs/health/2011/nr_110602_chp.pdf

18. Scottish Government. Living and dying well: a national action plan for palliative and end of life care in Scotland. 2015 [cited 2015 Jun 01]; Available from: http://www.gov.scot/Resource/Doc/239823/0066155.pdf

19. Scottish Government. Living and dying well: building on progress. 2015 [cited 2015 Jun 01]; Available from: http://www.gov.scot/Resource/Doc/340076/0112559.pdf

20. ComRes. National Council for Palliative care – public opinion on death and dying. 2015 [cited 2015 Jun 01]; Available from: http://dyingmatters.org/sites/default/files/files/National%20Council%20for%20Palliative%20Care_Public%20opinion%20on%20death%20and%20dying_5th%20May.pdf

21. Arnold E, Finucane AM, Oxenham D. Preferred place of death for patients referred to a specialist palliative care service. BMJ Support Palliative Care. 2013;0:1–322. Gomes B, Calanzani N, Gysels M, Hall S, Higginson IJ. Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliative Care. 2013;12:7


http://dyingmatters.org/sites/default/files/files/National%20Council%20for%20Palliative%20Care_Public%20opinion%20on%20death%20and%20dying_5th%20May.pdf

http://dyingmatters.org/sites/default/files/files/National%20Council%20for%20Palliative%20Care_Public%20opinion%20on%20death%20and%20dying_5th%20May.pdf

http://www.gov.scot/Resource/Doc/340076/0112559.pdf

http://www.gov.scot/Resource/Doc/239823/0066155.pdf

http://www.audit-scotland.gov.uk/docs/health/2011/nr_110602_chp.pdf

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/older-people-and-emergency-bed-use-aug-2012.pdf

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/older-people-and-emergency-bed-use-aug-2012.pdf

http://showcc.nhsscotland.com/isd/files/whole_system%20_wp1_text.pdf

23. Pollock K, Wilson E. Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at end of life. 2014 [cited 2015 Jun 01]; Available from: http://nets.nihr.ac.uk/__data/assets/pdf_file/0019/131734/FLS-10-2002-23.pdf

24. Audit Scotland. Review of palliative care services in Scotland. 2008 [cited 2015 Jun 01]; Available from: http://www.audit-scotland.gov.uk/docs/health/2008/nr_080821_palliative_care.pdf

25. Zheng L, Finucane AM, Oxenham D, McLoughlin P, McCutheon H, Murray SA. How good is primary care at identifying patients who need palliative care? A mixed-methods study. European Journal of Palliative Care. European Journal of Palliative Care. 2013;20:216-222

26. Mason B, Epiphaniou E, Nanton V, Donaldson A, Shipman C, Daveson BA, Harding R, Higginson I, Munday D, Barclay S, Boyd K, Dale J, Kendall M, Worth A, Murray SA. Coordination of care for individuals with advanced progressive conditions: a multi-site ethnographic and serial interview study. The British Journal of General Practice. 2013;63(613):e580-e588

27. Wallace J. Public awareness of palliative care: report of the findings of the first national survey in Scotland into public knowledge and understanding of palliative care. 2003 [cited 2015 Jun 01]; Available from: http://www.palliativecarescotland.org.uk/content/publications/PublicAwarenesso-PalliativeCare.pdf

28. Scottish Government. Overview of evidence relating to shifting the balance of care: a contribution to the knowledge base. 2008 [cited 2015 Jun 01]; Available from: http://www.gov.scot/Publications/2008/09/03103300/15


http://www.gov.scot/Publications/2008/09/03103300/15

http://www.palliativecarescotland.org.uk/content/publications/PublicAwarenesso-PalliativeCare.pdf

http://www.palliativecarescotland.org.uk/content/publications/PublicAwarenesso-PalliativeCare.pdf

http://www.ncbi.nlm.nih.gov/pubmed/?term=Murray%20SA%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Worth%20A%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kendall%20M%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Dale%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Boyd%20K%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Barclay%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Munday%20D%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Higginson%20I%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Higginson%20I%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Harding%20R%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Daveson%20BA%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Shipman%20C%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Donaldson%20A%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Nanton%20V%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Epiphaniou%20E%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.ncbi.nlm.nih.gov/pubmed/?term=Mason%20B%5BAuthor%5D&cauthor=true&cauthor_uid=23972199

http://www.audit-scotland.gov.uk/docs/health/2008/nr_080821_palliative_care.pdf

http://nets.nihr.ac.uk/__data/assets/pdf_file/0019/131734/FLS-10-2002-23.pdf

http://nets.nihr.ac.uk/__data/assets/pdf_file/0019/131734/FLS-10-2002-23.pdf

Documents

Living Well in Communities: Scoping and Design v1.0 · Web viewThe indicators are divided into two types of complementary measures; outcome indicators based on survey feedback, and,