Scotland

Multimorbidity Rehabilitation- The Sustainable Way Forward

Recognising that there is limited funding for “doing more of the same” we looked at how we could increase our cardiac rehabilitation capacity by broadening our scope and expertise to encompass a range of long term conditions that cause a high impact on unscheduled care. We acknowledged that multi-morbidity is becoming increasingly prevalent.

We subsequently developed The Healthy and Active Rehabilitation Programme (HARP) and opened up referrals to include people affected by stroke, cancer, COPD, falls, diabetes, and other long-term conditions.  HARP enabled us to widen our rehabilitation capacity to include cardiac groups which are typically excluded due to resource limitations: angina, arrhythmias and devices.  We designed a programme that would embrace activity, self management and support lifestyle change, across all of these groups.

Thus, the overall aim of this project was to proactively support prevention and self-management in an ageing population with increasing prevalence of chronic multiple morbidities. To help reduce health inequality the project has specifically targeted deprived and rural communities.

Secondary objectives 

  • To develop an evidence base for multimorbidity rehabilitation that would support a new way of working
  • To prove that this new model was sustainable

Student-Led Neurological Rehabilitation Group

Adults with long-term neurological conditions have low levels of participation in physical activities and report many barriers to exercise. This study used a mixed methods approach to evaluate participant experiences and outcomes following participation in student-led, community-based neurological groups and to explore the feasibility of performing a full-scale study.

The Falls Assistant tool

In 2011 in Scotland, approximately 8% of older people who fell received multifactorial assessment (MFA) and intervention delivered by NHS services. Our aim is to reach 20% by implementing the Falls Framework for Action for Scotland. Tests of opportunistic screening have demonstrated low uptake of MFA; many people don't want - or need - formal intervention from NHS services. A growing number of people over 60 use the internet (59%) with Scotland increasingly investing in technology solutions to improve health and well being. NHS 24's Smartcare Programme, provided the opportunity to explore the use technology to support self-management of falls risk. Our aim was to develop an online self management tool to enable users to assess falls risk and create a personalised falls prevention plan.

The East Lothian Discharge to Assess Service

Unnecessary delay in discharging patients from hospital is a systemic problem with a rising trend. In 2016/17 there were 532,423 bed days occupied by medically fit patients in Scotland. Over 70% were aged over 75. Current evidence highlights correlation between longer hospital stays and potential harm, resulting in poorer health outcomes, an increase in long-term care needs, poor patient flow and avoidable use of acute resources. Discharge to Assess (D2A) is a national driver and within East Lothian we looked to develop a pathway that supports discharging patients that are clinically fit and appropriate to have their Physiotherapy/Occupational Therapy assessments at home. We aimed to embed D2A as a core East Lothian service and promote a culture of 'ownership' of East Lothian patients throughout their patient journey.

Community Respiratory Team

To demonstrate how a specialist respiratory physiotherapy service placed in the community can prevent unnecessary hospital admissions in patients with COPD.

Grampian Home Oxygen Service

This project is an example of multiprofessional working that provides a safe service for patients whilst making cost savings. 

The new service was established in 2011 to manage Home Oxygen across Grampian. The multi-professional team provides all home oxygen (except for paediatric and cluster headache) based on a clinical need and risk management approach, and liaises with secondary and primary care. The revised service has demonstrated monthly cost improvements of £15 – 20k per month.

A web based prescribing system has been introduced this year by the contractor which offers easy access to updated information relating to individual patients use of oxygen.

Community Respiratory Team

The Community Respiratory Team supports patients living with Chronic Obstructive Pulmonary Disease (COPD) in their own homes.  They work with patients to improve self management of their condition and enable activity and enhanced quality of life when living with this long term condition. 

The project has resulted in shorter hospital stays, due to home based rehabilitation for COPD patients.

Development of Botulinum Toxin-A service in Fife, Scotland

I wanted to highlight the cost savings gained following a review and change of service delivery to children with focal spasticity in a district general hospital.  The purpose of the review and change was to improve the service we provided to children and their families in terms of timeliness on intervention, proximity to home and follow-up with known clinicians. 

Although the data is from 2014, we continue to inject less that 10% of our children under a general anaesthetic compared to 78% in 2009.

This service is led and delivered by a physiotherapist working in an extended role – initially Clinical Specialist, now Advanced Physiotherapy Practitioner with support from Orthopaedic and Neurology consultants.

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