East Lothian hospital at home and integrated care model is cited as example of good practice in latest Audit Scotland Report

The latest publication in Audit Scotland’s Changing Models of Health and Social Care series cites the ELSIE service, which supports people in East Lothian, as an example of good practice for Scotland.

ELSIE provides local GPs direct access to emergency care at home for their patients with a single point of contact for people who are at risk of admission to hospital. It also allows patients to be discharged earlier from hospital and supported at home. The system works by local GPs overseeing the local population’s health and social care needs, including triaging, treating and directly admitting patients to local hospitals if required.

Advanced Nurse Practitioners  are working with GPs’ and taking on roles, including home visits and prescribing in particular supporting and addressing significant GP workload in care homes. In addition to nurses, the extensive multidisciplinary team includes a consultant physician, physiotherapist, occupational therapist, pharmacist, community psychiatric nurse, carer link worker, and dedicated emergency care support and input by social work.

The team has a ‘huddle’ (a short meeting) every day to discuss the care patients need and any follow-up required once patients have been discharged from the service. To do this, the team liaises closely with GPs and district nurses as well as acute hospitals. The service is soon to extend to a 24-hour, seven day service and is working with the local primary care out-of-hours service to develop referral routes. 

East Lothian Integration Joint Board Chair Councillor Donald Grant says: ‘ELSIE is a great service and it has been so successful that we have already extended its operating hours so that it runs seven days a week from 8am to 8pm. We have had really good feedback from practitioners, patients and their families and we know that ELSIE is helping to deliver one of the East Lothian Health and Social Care Partnership’s key objectives – shifting the balance of care so that people can be cared for at home or closer to home.
‘The Audit Commission report says that generally across Scotland the shift to new models of care is not happening fast enough to meet the growing need – so ELSIE is at the forefront of good practice in Scotland. I would like to congratulate all the staff involved in ELSIE. The way staff from the various disciplines work together to achieve the best outcomes for the people they care for sets the standard that we aspire to across the East Lothian Health and Social Care Partnership.’