1. East Kilbride and Strathaven Liz Swan and Morag Hearty

2.  Population 88,000 approx.  Above Scottish average older age group  Scotland's first “New Town” in 1947  Both urban and rural areas  Mixed social strata  Large acute hospital –Hairmyres  Known locally for its traffic roundabouts, snow and Strathaven “toffee”.

4. District Nurses Physiotherapists GP Social workers Evening nurses Home carers Night nurses Social work OTs Discharge therapists Re enablement Older Person Family Other specialist services

5.  We needed to join people up into one team  That we should not create a bolt on team  Needs to be a neighbourhood model  To enhance existing knowledge, skills and practice, building confidence and resilience of the local workforce  To make the model sustainable  GP’s wanted to remain responsible medical officer for patients

6.  To provide safe, effective, person centred support to enable people to remain safely at home for as long as possible  When someone admitted to hospital support the person to return home as soon as possible  To support older people with complex health and social care needs to have their community care assessments carried out in their own home if possible

8. Older Person ICST 24 hour Nursing and Home Care Physiotherapists Occupational Therapists Social workers Re enablement staff Carers Support 3 rd Sector agencies Hospital discharge Independent Providers GP Family Other specialist services

10. We thought this was a fob off – how wrong could we have been It came at the right time Makes such a difference to work with the physiotherapist much better continuity of care A huge weight off my mind She listened to me-she understood it Delivered with a smile and a sense of humour! This is the future I was really impressed how everybody got together to do things Even during the night-amazing He is getting back to being independent No way can we go back It was no effort for me I was terrified to go to sleep – that has been a lifeline for me

11.  Adopted across NHS Lanarkshire  “Shared Care “ for tier 3 patients  Improve use of 3 rd sector  Direct links with A&E and Scottish Ambulance service  Step down beds in Care homes  Co Location  Scottish Health and Social care integration  Continue to listen to older people and their carers!