Me, my home, my community delivering seamless care across Cardiff - - PowerPoint PPT Presentation

‘Me, my home, my community’ – delivering seamless care across Cardiff and Vale of Glamorgan

Regional Partnership Board Update PSB 20 November 2018

Role of the RPB

• Regional Partnership Board’s role is to:
• Ensure partners work effectively to improve outcomes for people in their

area.

• Ensure the partnership bodies provide sufficient resources for the

partnership arrangements, in accordance with their powers under section 167 of the Act

• Determine where integrated services, care and support will be most

beneficial to people within their region, informed by the views of service users.

• Ensure partners prioritise integration with respect to:

Older people with complex needs and long term conditions,

including dementia;

People with learning disabilities; Carers, including young carers; Integrated Family Support Services; Children with complex needs due to disability or illness.

• The Partnership Arrangements (Wales) Regulations 2015 require that each

regional partnership board must prepare an annual report on the extent to which it has met its objectives.

Governance Structure

Our vision for delivering seamless care is underpinned by our 4 design principles…

4

Cardiff and Vale of Glamorgan Regional Partnership Board ‘s Design Principles A Healthier Wales’ Vision

Learning from Canterbury, NZ…

• Vision – consistent and

compelling vision

• Clinical engagement and

empowerment

• Culture – permissive and

accountable

• Patient/Citizen centred –

system wide “It should be seamless for the person...they have no sense of having been passed from one organisational structure to another...the services are just organised around them”.

Integrated Care Fund 2018/19

£ Frail Older People: £3.743m, LD/CwCN: £1.737m, WCCIS: £201k, Autism: £367k, Capital: £3.810m

What’s worked well?

• Focused effort upon the needs of key population groups;
• Encouraged partners to work collaboratively with a focus

upon best practice;

• Use of Results Based Accountability as an outcome

focused performance management model;

• Helped people to think

innovatively and test new ways of working;

• Focus upon community;
• Managing demand from

population growth.

RPB Target: 25% reduction on June 2015 position (maximum of 82 patients)

‘Get Me Home’ Plan – Delayed Transfers of Care

Impact of the Preventative Approach

Independence and Wellbeing First Point of Contact Stable Non-Complex Care Intensive and/or Enhanced Long Term, Stable Complex Care Specialist

WELLBEING COORDINATOR

10

New Service Model

• Services promote prevention, health and wellbeing, independence

and empowerment, recognising that a wide range of social and health needs may have an impact on a persons wellbeing.

* e.g. Public Health / Healthy Communities , Community Networks / Befriending, dementia friends, Leisure and Learning Activities, Information and Advice

• Services provide a first point of contact, they screen and assess,

providing early intervention and sign posting. Where a persons needs are stable and not complex, services provide routine on-going support.

*e.g. Contact Centres, Equipment / Aids, Third Sector, Care & Repair, GP and Dental Surgeries, Sheltered Housing, Independent Living Service, Day Opportunities

• Services provide a flexible and coordinated response to a persons

rising unstable need. They either provide, an intensive reablement service or an ambulatory care intervention. Both prevent inappropriate long term care and avoid hospital admissions.

* e.g. Occupational Therapists, Telecare Plus, Domiciliary Care, Community Resource Teams, Step Up / Down Accommodation, Mental Health Teams , Frail Older Persons Advice and Liaison Service, Elderly Care Assessment Service

• Services provide for people whose needs are not necessarily low but

are stable, additional support may be needed to meet daily living

• needs. Rising complexity can mean care planning by specialist multi-

disciplinary teams to avoid unstable acute hospital admission.

*e.g. Extra Care Accommodation, District nursing, End of Life Care, Residential Care Homes, Nursing Care Homes

• Services provide for people whose needs are highly unstable and/or

for highly specialist assessment and care. Integrated discharge planning supports timely discharge.

*e.g. Specialist Assessment, Inpatient Services, Integrated Discharge Team * NB some services will fall under more than one tier of intervention

Joint Commissioning and pooled budgets

• Mapped core resources
• Cluster analysis to inform locality working
• Completion of ‘Housing with Care and Care Ready’

research – what accommodation do we need to build by 2035 and where…

• It is forecasted that by 2035 Cardiff will

require an additional 1,787 older people's housing units, 609 housing with care units and 655 nursing care beds.

• New Health, Housing and Care

Programme Board – reports to RPB

Locality Working

• Completion of ‘Perfect Locality’ specification
• Development of Hubs and Well-being Centres
• Mapping of social prescribing and well-being services
• Sheltered blocks refurbished - modernised and

accessible with services on site for wider community of

• lder people – could be social activities / health and

advice services

• Development of neighbourhood/cluster care networks

using local assets, staff and services

• Sustainable ‘careforce’ across the statutory,

third and independent sectors

• Asset based community development

A Healthier Wales

“Delivering a whole system approach to health and social care which is focussed on health and well-being, and on preventing illness”

Our Proposal

Accelerated Cluster Development Seamless Social Prescribing Developing a Single Point of Access for GP Triage Get Me Home Preventative Services Get Me Home Plus Developing an ACE Aware Approach to Resilient Children and Young People Developing Place Based Integrated Community Teams

7m

Next Steps

• Delivering a Partnership Response to ‘A Healthier Wales’ – including

2nd Transformation Bid by Christmas

• Continued emphasis on prevention, neighbourhood/cluster working

and community networks

• Embedding social prescribing / wellbeing approaches – utilising local

assets

• Development of an in-hospital ‘front door’
• Continued development of multi-agency hubs and well-being centres
• Continue to develop multi-disciplinary locality teams with integrated

management structures

• Review of Area Plan delivery in March 2019
• Relationship of RPB and PSB – Social Care Wales undertaking national

review to report back in New Year