About the project

The Fife Shine 2011 team is implementing a range of initiatives to support older people to live and thrive at home in ways that are safe and sustainable. This involves harnessing community resources such as businesses and care cooperatives, and developing ‘micro-enterprises’. 

These micro-enterprises will allow older people to access tailored packages of care that are personalised to them and their family. The care provided through these packages is preventive, timely and will strengthen self-reliance and resilience in individuals, families and communities.

For example, currently, an older person will be admitted to hospital following a fractured wrist if they are unable to care for themselves. Under this initiative, a micro-provider will respond to the situation, providing meals and personal care as necessary, to allow the older person to recover from their injury at home.

Older people will benefit from care that is tailored to their specific needs and which is delivered by micro-providers, who are often already known to them as friends or neighbours. Anticipatory services will respond to early warning signs, which will reduce hospital admissions. Informal carers will feel better supported to provide care.

The team hopes that having a wider range of flexible care options for older people will reduce the number of people whose discharge from acute and community hospital is delayed.

Why this project?

There has been a 76% rise in emergency admissions of people aged 65 and over in Fife over the last 10 years. Referrals to community teams have also risen significantly over the last three years. Social care services are severely stretched, which delays discharge from hospital. In Fife, 50% of community beds are filled with people who could be better cared for at home.

Many frail, older people admitted to hospital have had a ‘crisis’, leading to them being unable to manage at home. In the majority of cases, there is a gradual deterioration, which, if identified early, could result in interventions to prevent admission. Recognising this, however, requires knowledge of how certain factors may suggest that something is about to go wrong. In the frail and elderly, such factors include increased forgetfulness, walking less well or missing meals. These types of concerns are hard to self-report and are therefore dependent on others noticing. Healthcare professionals, as they currently practice in the community, do not have the opportunity to do this for the majority of patients. 

Local people have said they want low-tech, coordinated care at home, yet, despite recent advances, the system is still primarily set up to provide an institutional response and reactive care.