EAST AYRSHIRE COMMUNITY PLANNING PARTNERSHIP SINGLE OUTCOME AGREEMENT ANNUAL PERFORMANCE REPORT 2013/14: OUTCOME SUMMARY

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1 EAST AYRSHIRE COMMUNITY PLANNING PARTNERSHIP SINGLE OUTCOME AGREEMENT ANNUAL PERFORMANCE REPORT 2013/14: OUTCOME SUMMARY National Outcome 6: We live longer, healthier lives. National Outcome 7: We have tackled the significant inequalities in Scottish society. Local Outcomes Progress 2013/14 Increase in life expectancy at birth Active, healthy lifestyles and positive behaviour change promoted Alcohol and drug related harm reduced Older people, vulnerable adults and their carers supported, included and empowered to live the healthiest life possible males females X X Reduction in deaths from coronary heart disease (under 75 years) Reduction in deaths from all cancers (under 75 years) Reduction in smoking prevalence Maintain pregnancy rates (under 16 years) Reduction in patients hospitalised with alcohol conditions Reduction in patients hospitalised with drug related conditions Increase in the number of people who have been detoxified to zero from prescribed medication Number of people newly diagnosed with dementia offered Post Diagnostic Support; and number and percentage of people receiving the offer accepting this support 44

2 East Ayrshire Community Planning Partnership Single Outcome Agreement: Annual Performance Report 2013/14 National Outcome 6: We live longer, healthier lives. National Outcome 7: We have tackled the significant inequalities in Scottish society. PROGRESS IN IMPROVING THE DELIVERY OF THE NATIONAL OUTCOME Community Planning Partners have in place a range of structures and operating arrangements to ensure effective progress against the planned local outcomes and related national outcomes contained within the Single Outcome Agreement. The key drivers for change are summarised below: The Community Plan Improving Health and Wellbeing Action Plan , which was reviewed in 2012/13 within the context of the Community Planning Mid Term Review, sets out our strategic priorities and local outcomes, which are responsive to both the local and national agendas, particularly in a time of reducing resources, and are as follows: Strategic Priority: Improving physical and mental health, wellbeing and care, and reducing health inequalities. Local Outcomes: Active, healthy lifestyles and positive behaviour change promoted Alcohol and drug related harm reduced Impact of multiple deprivation and poverty on the health and wellbeing of the most vulnerable individuals and communities addressed Older people, vulnerable adults and their carers supported, included and empowered to live the healthiest life possible Children and young people, including those in early years and their carers, assisted to be active, healthy, nurtured and included. In 2013/14, the Community Health Partnership (CHP) continues to provide an effective delivery mechanism, which is fully integrated within Community Planning, strengthening our partnership working and supporting the delivery of health related outcomes. As an integral element of the CHP structure, the Officer Locality Group for Adults and Older People continues to provide a strong and effective partnership mechanism to implement and respond to local and national policies and strategies Over the last year, the Officer Locality Group for Adults and Older People, which is the main structure for planning adults and older people s partnership services in East Ayrshire, continued to focus on specific work streams, including: Older People; Long Term Conditions; Rehabilitation and Enablement; Mental Health and Learning Disabilities; Financial Inclusion; Alcohol and Drugs; and Improving Health and Reducing Inequalities. The national alcohol and drug strategies, namely Changing Relationship with Alcohol and The Road to Recovery, signalled a change in national strategic direction for those with alcohol and other drug problems from targets which measured engagement and maintaining people in treatment to focused person centred outcomes. Alcohol and drug treatment continues to be monitored and directed through the Alcohol and Drug Partnership for East Ayrshire. The Alcohol and Drug Partnership Strategy for East Ayrshire has been developed with a clear focus on prevention. Joint action includes partnership efforts to examine issues such as overprovision, diversionary activities and education. Our move from treatment to recovery involves a holistic approach to tackling the wider social determinants of addiction. There is also a significant focus on harm reduction for young people through a programme approach. With regard to progressing the agreed development areas in relation to our SOA , going forward further analysis of the impact of alcohol and drugs in our communities will be progressed, leading to service redesign to support the recovery of individuals, families and communities. This work will be led by the

3 Alcohol and Drug Partnership. Ayrshire College s Strategic Plan and Outcome Agreement for outline a number of key objectives which support a strategic goal of tackling inequalities. In partnership with NHS Ayrshire and Arran, Ayrshire College appointed Scotland s first NHS Addiction Liaison Officer who supports the health and wellbeing of the students, staff and the wider Ayrshire community. This unique appointment provides an opportunity for the College to contribute to improving health and life chances across Ayrshire by being proactive in engagement with college students, particularly year olds and hard to reach groups. This post will enhance the understanding of substance misuse and related issues amongst the student population, particularly young people who often have little accurate knowledge of mental health issues and the effects of drugs, alcohol and other substances. In March 2011, NHS Directors approved recommendations for roll out and sustainability of service delivery of Long Term Conditions Management, including integration of the key objectives within Ayrshire and Arran NHS Board s Health Care Quality requirements, HEAT Targets, Local Delivery Plan action, Community Health Partnership plans and local Single Outcome Agreements. Long Term Conditions Management supports integration across directorates, services and Managed Clinical networks, and facilitates partnership working with a range of key stakeholders, including partners, patients and the public through CHP planning infrastructure. All interventions have a strong local and national evidence base and include a Long Term Conditions enhanced service, national development of SPARRA (Scottish Patients at Risk of Re-admission and Admission) integrated record keeping, telehealthcare and integrated health and social care pathways. Partnership working has been supported nationally through Reshaping Care for Older People and the establishment of the Change Fund to be utilised in partnership to reshape older people s services. This fund is intended as a lever to support service change in mainstream services and improve long term outcomes for older people in partnership with the third and independent sectors. Change Fund resources have been made available up to 2014/15. On 1 April 2014, management responsibility of health and social care services in East Ayrshire transferred to the newly established East Ayrshire Health and Social Care Partnership. This new and inclusive partnership, involving Councillors and NHS Board Members alongside people who use services, family carers, the voluntary sector and local professional and employee representatives. New Scottish Government legislation, namely The Public Bodies (Joint Working) (Scotland) Act 2014 means that all community health and social care services for adult and older people s services must be included in the partnership. In recognition of the many challenges faced by local communities cut across all age groups, the East Ayrshire Partnership includes social work services, incorporating Children and Families and Criminal Justice alongside similar health services. In preparation for the change, the Director of Health and Social Care for East Ayrshire was appointed in February 2014 to support a Shadow Integration Board in leading the integration of public sector services in East Ayrshire. During the shadow year of 2014/15, current arrangements will be reviewed and new proposals will be developed leading to full service integration by 1 April Health inequalities and inequalities in general are complex problems which go beyond the understanding and response of any single agency. While the Community Planning Partners recognise that the services delivered across East Ayrshire are making a difference to the lives of many individuals, groups and communities, the gap between the most and least disadvantaged communities has not narrowed. If health inequalities are to be reduced, it is widely accepted that radical change is required on how we work both individually and collectively, with and in our communities. The integration of health and social care will be a further opportunity to address the deep seated health inequalities by focusing social care and wellbeing in the regeneration of our communities.

4 PROGRESS AT MARCH 2014 ON LOCAL OUTCOMES Local Outcome Active, healthy lifestyles and positive behaviour change promoted Indicator/s (noting frequency/ type/source) Life expectancy at birth - males/females Annual/NHS Ayrshire and Arran (General Register Office for Scotland Life Expectancy for Administrative Area within Scotland) Deaths per 100,000 population from coronary heart disease (CHD) (under 75 years) Annual/NHS Ayrshire and Arran (ISD Scotland) Deaths per 100,000 population from all cancers (under 75 years) Annual/NHS Ayrshire and Arran (Scottish Neighbourhood Statistics) Baseline at 2011/ years males 79.5 years Females ( ) 47.7 (2011) (2011) Progress at March years males 80.2 years females ( ) 45.1 (2012) (2012) Progress target/s to 2014/15 (where available) Increase in life expectancy Reduction in mortality rate for coronary heart disease Reduction in mortality rate for cancer End target/s and timescale/s or direction of travel Increase in life expectancy Reduction in mortality rate for coronary heart disease Reduction in mortality rate for cancer Current status Smoking prevalence Every 2 years/scottish Public Health Observatory (ScotPho ) East Ayrshire CHP Health and Wellbeing Profiles/Scottish Household Survey Pregnancy rates per 1,000 population among under 16 year olds (annual reporting of 3 year rolling average) Annual/NHS Ayrshire and Arran (ISD Scotland) 27% (2009/10) 7.9 per 1,000 females aged years ( ) 32.3% (2011/12) 7.0 per 1,000 females aged years ( ) Reduction of two percentage points per two years in smoking prevalence (provisional target) Maintain pregnancy rates among under 16 year olds Reduction in smoking prevalence Longer term targets to be further considered by the Multi Agency Sexual Health Programme Board. Key: Improving progress Maintaining progress = Improvement required X Data unavailable O X

5 Summary of progress and achievement 2013/14: Key performance highlights and success during 2013/14, which will contribute to promoting active, healthy lifestyles and positive behaviour change, are summarised below. Physical activity, healthy eating and positive behaviour change promoted: A range of activities and interventions to support and encourage physical activity and healthy eating continues to be delivered and well received in communities across East Ayrshire. Over the last year, a range of programmes has been accessed by local people, including 11,537 attendances at physical activity programmes (exercise classes and health walks and falls prevention classes), against a target of 10,000 and an additional 830 attendances at the Mind Your Step walking programme in Crosshouse and Ailsa hospitals; 4 community led groups established at Dean Castle Country Park, Auchinleck, Kilmaurs and Fenwick; 3,199 attendances recorded at Community Health Improvement (CHIP) Van outreach services, against a target of 2,000 attendances; 504 new referrals to the Activity on Prescription initiative, against a target of 500; play, sport and health related activities delivered in support of 6 local and national campaigns, including Alcohol Awareness Week, Suicide Prevention Week, Play Day, Men s Health Week, Learning Disability Awareness Week and Equalities Week; and 20,000 attendances recorded as athletes, officials, volunteers and spectators travelled to the Ayrshire Athletics Arena to take part in a range of events such as the Central and South of Scotland Athletics League, Scottish Youth Development league, West District Track, and Field Championship and West District Cross Country Championships. In addition, a draft Healthy Weight Strategy and Action Plan was developed through joint working between NHS Ayrshire and Arran, the three Ayrshire authorities, and the North Public Partnership Forum. This work will continue to be progressed in 2014/15. Oral Health: Significant investment has been placed both nationally and locally on improved oral health. The partnership focus on both early years, adult and older people s oral health continues to demonstrate a preventative approach and good practice in relation to the development of training among partners, working with vulnerable groups and developing relationships with communities. This work has been particularly successful within the North West Kilmarnock area. In 2013/14, all head teachers (42) in East Ayrshire s primary schools completed training on application of Search for a Smile and the programme rolled out to all primary schools; a total of 13 local childcare establishments are participating in oral health activity across Cumnock and Doon Valley; 5 marketing activities developed to increase access to oral health, including community development activity which engaged with 373 people, 15 community engagement sessions across East Ayrshire, including nurseries, primaries and community groups, and 11 pharmacies participating oral health promotion as part of the Ayrshire wide Choose a smile for your child programme; and the Oral Health in the Workplace Programme has been reviewed and embedded in NHS Ayrshire and Arran programme delivery; oral health training has been developed for prison staff at HMP Kilmarnock, five oral health champions received training and a total of 2 training sessions were facilitated; Caring for Smiles training programme and oral health champions established in 20 of 21 care homes for older people, three oral health promotion assistants recruited to support delivery and roll out of training, 2,851 patients were treated through the Dental Teach and Treat at North West Kilmarnock Area Centre, which has provided access to dental services for vulnerable groups, particularly older people, people with learning disabilities, prisoners on release and homeless individuals, including 926 new patients in 2013/14. A fall in demand for this service (from 3,177 patients in 2012/13, including 1,188 new patients) may be attributed to 92% of all dental practices in Ayrshire currently accepting new NHS patients. Tobacco: Smoking cessation remains a priority for the partnership, and the focus for this work continues to be on delivering a smoking cessation service across East Ayrshire targeted in areas of deprivation. ISD data for January to December 2013 indicated that 2,219 smokers in East Ayrshire had used services to support them to stop smoking. The Tobacco Control Strategy has a three year action plan which covers protection, prevention and cessation and is in year three of implementation. The actions under protection have included a local smoke free homes and cars campaign which has targeted key groups and settings such as early years and nurseries. Work has also been undertaken with trading standards in relation to sale of cigarettes to young people and in respect of counterfeit tobacco. A national smoke free home campaign has also been widely supported locally. Prevention activities have included training of key staff and the development and distribution of support resources. Smoking cessation services are provided by local Community Pharmacies and by a Specialist service. There is close co-operation and joint working between these services to ensure that people who want to stop smoking receive the support

6 best suited to their needs and level of smoking. Smoking cessation groups are all within areas where data indicates there are high levels of smoking. Key vulnerable groups are also targeted such are pregnant women, prisoners and young people. Teenage pregnancies: The most recent available data reflects that there has been a reduction in the number of teenage pregnancies in East Ayrshire from 11.1 per 1,000 females aged years ( ) to 6.2 per 1,000 females aged years ( ). Sexual Health: Sexual Health information and advice has been delivered by partners through educational and community resources. This has led to an increase in awareness and increased uptake in access to services, particularly among our young people. This work has been undertaken using a variety of media and has been particularly successful through the use of the Internet, in particular through the Sexual Health Ayrshire (SHAYR) website. At March 2014, there was increase from the baseline (21 sign up facilitators at October 2012) to 29 sign up facilitators for the C Card scheme and 18,510 hits on the SHAYR website at were recorded in 2013/14, an increase of 18% on the baseline position (15,700 hits at April 2010). In the 12 months the to July 2014 the following services were delivered that provide gay and bi sexual men with the skills and knowledge to make positive decisions about their sexual health and wellbeing: 27 hours of support provided through the Gay Men s Services(GMS) Worker for Ayrshire and Arran; 36 hours of Public Sex Environments (PSE) outreach; 72 hours of; 52 hours of group work supporting those individuals living with HIV; and over 32,200 condoms and lube distributed locally through the condoms by post scheme. Ayrshire College, the Student Association and the NHS Addiction Liaison Officer, along with curriculum areas such as sport and fitness, promote health and wellbeing among its student population through a range of campaigns, awareness-raising events and social media. Ayrshire College sport and fitness students, acknowledged for the work they do with local communities, work with Active Schools on a range of activities. The College s students and staff have particular expertise in supporting sports activity for people with disabilities, and students undertaking sports courses in Kilmarnock engaged with local communities in East Ayrshire on this issue.

7 Local Outcome Alcohol and drug related harm reduced Indicator/s (noting frequency/ type/source) Patients hospitalised with alcohol conditions per 100,000 population Every 2 years/scottish Public Health Observatory (ScotPho) East Ayrshire CHP Health and Wellbeing Profiles Patients hospitalised with drug related conditions per 100,000 population Every 2 years/scottish Public Health Observatory (ScotPho) East Ayrshire CHP Health and Wellbeing Profiles Number of people who voluntarily have been detoxified to zero from prescribed medication Annual/NHS Addiction Services Baseline at 2011/12 1,538 ( ) ( ) 39 (2011/12) Progress at March (2011) (2011) 51 (2013/14) Progress target/s to 2014/15 (where available) Reduction in alcohol related hospital admissions Reduction in patients hospitalised with drug related conditions Increase in the number of people who have been detoxified to zero from prescribed medication End target/s and timescale/s or direction of travel Reduction in alcohol related hospital admissions Reduction in patients hospitalised with drug related conditions Increase in the number of people who have been detoxified to zero from prescribed medication Key: Improving progress Maintaining progress = Improvement required X Data unavailable O Current status X

8 Summary of progress and achievement 2013/14: Key performance highlights and success during 2013/14, which will contribute to a reduction in alcohol and drug related harm, are summarised below. Alcohol and Drugs Partnership (ADP): In 2013/14, two ADP information sessions/consultation and engagement events were delivered as follows: Recovery Information Seminar at the Grand Hall (60 participants) and Recovery Conversation Café event (40 participants). Additional activity included the following: Practitioners Forum established with an average of 15 participants; NPS (Legal High Awareness) training delivered, including a 1x hour staff training programme for 83 Addiction services, 28 in patient mental health staff and 35 community mental health staff; a two-hour NPS briefing session developed and delivered for the three Ayrshire ADPs, with 73 participants from East Ayrshire. Drug and Alcohol Education in Schools: The Substance Misuse Education programme has been embedded into the school curriculum in all East Ayrshire secondary schools and continues to deliver preventative programmes; external agencies have supported delivery of lessons in relation to substance misuse, including the SPICE Roadshow, which included the theatre production Take a Drink by PACE Theatre Group attended by 1,278 S3 pupils, followed by a series of expert workshops run by St Andrew s First Aid, WISE (The effects of substance misuse on your future and family) Barnardos, and Police Scotland (legal highs). A total of 1,253 S2 pupils took part in the Kamikaze Road Show and watched the theatre production Kamikaze by Baldy Bain Theatre Group before participating in a series of No Knives Better Lives workshops run jointly by Police Scotland s Campus Cops, the Health and Wellbeing Coordinator, Vibrant Communities and Barnardos. Over 10,000 children and young people consolidated their understanding of how to keep safe, harmful chemicals and where to get help by completing EAC s 3-18 substance misuse programme in our educational establishments. The Jenny and the Bear resource was used in primary schools across East Ayrshire to raise awareness of the health issues surrounding second hand smoking (approximately 900 P1 pupils benefited). Teachers plans developed with external agencies to support the delivery of lessons; 68 training sessions delivered to over 3,600 participants; 330 education staff participated in the e-learning module to supplement their knowledge of alcohol and drug awareness; 40 staff attended resource training sessions; NHS Addictions delivered CPD training to 10 schools for 700 participants; 24 Council staff who work with young people completed the Scottish Mental Health First Aid for young people course.; information on alcohol and drug services available in schools/education establishments though the availability of credit card style help cards designed by young people (6,000 secondary pupils), pop up banners displayed in all nine secondary schools, and NHS Addiction services delivered specialist lessons to senior secondary pupils and/or drugs awareness to S6 peer educators (topics covered included Alcohol and Risky Behaviour, legal Highs (NPS), Blood Borne Viruses, and Substance Misuse and Driving); NHS Ayrshire and Arran and the Council s Vibrant Communities Team delivered alcohol/drug (legal high diversionary activities awareness sessions at 12 primary school parent evenings, reaching 372 participants; awareness raising sessions were delivered in 26 primary schools on issues such as the effects of high caffeine drinks, alcohol, smoking and drugs (illegal and legal highs). Alcohol and drug related information was delivered to parents/guardians and young people at 12 school parents evenings for 372 participants. Community Interventions: Activity for children and young people also continue to focus on prevention in the community setting through positive sport and leisure activities in partnership with the Vibrant Communities team, with 27,677 attendances recorded by children and young people at positive/diversionary sport activities against an annual target of 25,000; and 5,419 alcohol brief interventions delivered, against a target of 4,076. A national alcohol awareness campaign was supported locally and 50 drug awareness information sessions were delivered in communities, including 700 measuring cups distributed; alcohol awareness information issued to over 250 participants on the community based exercise programme; 1,000 drinks mats providing alcohol awareness information distributed to pubs and hotels; 220 establishments (shops, hotels and pubs) targeted for distribution of drinks mats with QR codes linked to NHS Choices, providing access to alcohol awareness information via smart phones; and vinyl posters produced with a focus on foetal alcohol syndrome. Safer drinking messages tweeted to 5,500 people. The Lighthouse Foundation has delivered the charity s STOP Project, including information sessions, to 1,360 young people aged years in East Ayrshire; foetal alcohol spectrum disorder information delivered to 75 young people aged years. Prevention and early intervention activity for children and families affected by parental substance misuse continues to be a priority.

9 Children Affected by Parental Substance Misuse: The ADP continues to lead on a number of initiatives directed at improving working between addiction services and children and families. All women presenting to maternity services are screened for alcohol related issues, which resulted in 1,176 antenatal alcohol screenings and 625 antenatal alcohol brief interventions; follow up and support service provided. A total of 73 families and 79 children were affected by a family member' addiction alcohol/drugs. Around young carers affected by parental alcohol abuse per month attended groups and one to one support; 11 children aged 3-11 affected by parental addiction received Play Therapy; 20 children regularly attend weekly children and young people s groups; and 80 children and their carers access family respite day trips Overdose training is provided to recipients of Naloxone kits, with 393 take home kits issued in 2013/14, compared to132 kits issued the previous year. NHS addiction staff and Social Work staff have developed closer working links via dedicated provision under the early year s collaborative framework and ongoing discussions are taking place towards the collocation of these staff. Recovery Oriented Systems of Care: A move from treatment to recovery has been embedded within the Improving Health and Wellbeing Action Plan and initiatives that seek to promote recovery will be a continuing priority. NHS Addiction Services provide an open referral system to ensure timeous and easy access to recovery orientated treatment intervention and 99% individuals receive their first appointment within 3 weeks o referral.. A total of 920 individuals wee referred to Alcohol Addiction Services, with 314 people with planned discharges. Activity to support individuals recovering form problematic drug and alcohol misuse includes the following: Addiction alcohol and drug recovery service delivered 2,118x one to one sessions and 105x group work sessions and provided volunteer work placement options. Next steps programme offered opportunities to 9 individuals to participate in further education opportunities. Three cooking groups operated over the year and 48 gym inductions were delivered across East Ayrshire Leisure Trust Body station facilities, mainly in the Hunter Centre (North West Kilmarnock Area Centre). A total of 185 individuals attended sessions delivered by Artistic Creations, a charity established by individuals in recovery to provide opportunities to participate in artistic activity to support physical and mental wellbeing and promote cross community group working Fourteen families and family members with addictions received mediation. SACRO prison alcohol through care service is targeting repeat alcohol offenders, with 75% reporting reduced alcohol use in the community; 81% of 117 referrals to ACA criminal justice service showed reduction in offending; and 44 families received support from the Lighthouse Foundation s Prison Project.

10 Local Outcome Older people, vulnerable adults and their carers supported, included and empowered to live the healthiest life possible Indicator/s (noting frequency/ type/source) Number of people newly diagnosed with dementia offered Post Diagnostic Support; and number and percentage of people receiving the offer accepting this support Monthly/NHS Ayrshire and Arran Baseline at 2011/ Patients newly diagnosed with dementia (2011/12) Progress at March Patients newly diagnosed with Dementia (2013/14) 90 (39.0%) Patients offered Post Diagnostic Support (2013/14) 80 (88.9%) Patients receiving the offer accepting this support (2013/14) Progress target/s to 2014/15 (where available) All people newly diagnosed with dementia will have a minimum of one year s Post Diagnostic Support co-ordinated by a link worker, including the development of a Person Centred Support Plan by (NHS HEAT Target) End target/s and timescale/s or direction of travel An increasing number of people with dementia who wish to remain at home will be supported appropriately to achieve their outcomes. Current status Summary of progress and achievement 2013/14: Key performance highlights and success during 2013/14, which contribute to supporting vulnerable adults to live the healthiest life possible, are summarised below. Mental Health: Delivery of the Integrated Resource Framework Action Plan continues to be progressed with recommendations integrated into practice. The CHIP Team continues to deliver training and education to agency employees and the wider community to assist in early identification of suicide risks and facilitate access to appropriate supports. The annual suicide prevention campaign is supported in September each year in East Ayrshire. Safe Talk (suicide alertness training) was provided to 99 people from East Ayrshire, against a target of 100; and 83 people from East Ayrshire participated in 6x (Applied Suicide Intervention Skills Training) ASIST courses. In excess of 40 service users affected by mental disorder were supported to access screening services, including physical health checks; staff facilitated service users at GP appointments; and increased physical health assessments at Clozapine clinics and expanding to all patients on long term neurocleptic medication; psycho-education, treatment sessions and relapse prevention. A single point of contact for people with an autism diagnosis opened in Kilmarnock to sign post to appropriate services. Dementia: East Ayrshire Dementia Action Plan continued to be implemented in 2013/14. Within East Ayrshire at March 2014 there were 985 people on the GP Dementia Registers. All people newly diagnosed with dementia receive a minimum of one year s Post Diagnostic support, with 90 patients offered support, of which 80 accepted support in 2013/14. Post diagnostic support delivered by the Alzheimer Scotland Link Worker who is integrated in the North West Community Mental Health Team in Kilmarnock and provided by the Auchinleck Community Mental Health Team, with a post diagnostic support group established in this area. Training was delivered for Health, Local Authority, Police Scotland, Scottish Fire and Rescue Service, Third sector and independent sectors as follows: individuals trained at Skilled Practice level; 246 individuals trained at Enhanced Practice level; and 246 individuals trained at Expert practice level. Care home staff were supported by the Dementia liaison nurse, which resulted in 226 new referrals; 526 return visits and 64 medication reviews.