Me, My Home, My Community Cardiff and Vale of Glamorgan Regional - - PowerPoint PPT Presentation

“Me, My Home, My Community”

Cardiff and Vale of Glamorgan Regional Partnership Board response to ‘A Healthier Wales’

30 January 2019

The Regional Partnership Board

Representation Cardiff and Vale University Health Board Cardiff Council Cardiff Third Sector Council Glamorgan Voluntary Service Carers Representatives Registered Social Landlord representatives Third Sector Private Sector Population Groups Older People Children with Complex Needs Learning Disabilities Carers Integrated Autism Service Children Mental Health Dementia

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

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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

• f having been passed from one organisational structure to

another...the services are just organised around them”.

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Not starting from scratch…

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

WELLBEING COORDINATOR

Crisis Or Emergency Intervention

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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

P r e v e n t i

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Care at Home and in the Community Supra Regional R e g i

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a l Enhanced Local Local Within each of the three Localities we are developing a Health and Wellbeing Centre Within each of the clusters/neighbour- hoods we would like to create Wellbeing Hubs with partners

Wellbeing

HUB

An Integrated Network of Hospital and Community Care and Well-being

‘Me, My Home, My Community’ (Part 1)

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

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What we’ve learnt as a Partnership…

• It has taken time to build relationships and a shared vision but

it’s now paying off in terms of pace of change

• A focus on ‘place’ gets us out of our organisational silos
• Strengths based approaches are at the heart of our approach
• We’re thinking differently as to who can deliver what across the

whole system

• Partnership funding has been an important tool in facilitating the

delivery of shared priorities (but short-term nature hasn’t helped!)

• There needs to be alignment of planning, performance and

funding frameworks so we have collective drivers

• We are at an important step for transformational change and we

must deliver!

Any Questions?

For further information:

Hsc.Integration@wales.nhs.uk www.cvihsc.co.uk