REVIEW OF ICF PROJECTS AND INITIATIVES WHICH DEMONSTRATE GOOD - - PowerPoint PPT Presentation

‘REVIEW OF ICF – PROJECTS AND INITIATIVES WHICH DEMONSTRATE GOOD PRACTICE’

ICF LEARNING EVENT CITY HALL, CARDIFF 27TH SEPTEMBER 2017 Dr Tony Garthwaite

AIM OF REVIEW

• 1. What has worked well?
• 2. Why should it be regarded as good practice?
• 3. Identify learning points and implications for

future guidance

N.B. Projects and initiatives up 2016/17

A REVIEW NOT AN EVALUATION

• No negatives
• No buts
• No attempt to arrive at an overall conclusion on

effectiveness of the fund Nevertheless, a good insight into the value of ICF and its future use

THE REPORT

• 40 projects and initiatives
• 28 Case Studies
• 15 features and characteristics
• Contributions from all regions
• A common template of criteria
• Projects chosen by regions
• The quarterly and annual evaluation reports
• Conclusions = a basis for learning

THE CRITERIA FOR INCLUSION – THE WHAT IS WORKING WELL? QUESTION

Projects/initiatives must have achieved at least one of the following:

• Improved the co-ordination of care
• Developed new models of care
• Assisted in avoiding unnecessary hospital admissions and delayed

discharges

• Promoted and maximised people’s independence
• Supported people’s recovery and recuperation

N.B. Guidance did not require all criteria to be met. However, important that they support integration and prevention

THE CRITERIA FOR INCLUSION – THE WHY IT’S WORKING WELL? QUESTION

Projects/initiatives must be able to claim to have achieved at least one of the following:

• Encouraged integrated working, demonstrating the role and contribution of all

the relevant partners in the region.

• Shifted the way services are delivered and/or the ways the collaborating
• rganisations work, indicating how the project/initiative is considered to have a

long term impact and achieve sustainable services.

• Provided a new or additional service
• Delivered benefits and positive outcomes for older people in particular how the

project/initiative enhances the provision of integrated services

• Aligned with national and regional strategic priorities
• Been well managed through a rigorous and transparent governance framework

with clear leadership accountabilities, milestones and progress measures.

LEARNING AND CONCLUSIONS

Learning comes from:

• 1. The narrative accompanying each project in the appendix

together with the case studies section

• 2. The features and characteristics described in Section 2
• 3. The summary headings in Section 3 of how projects have been
• rganised and delivered to meet the objectives and aspirations of

the fund

• 4. The evaluation reports, particular those undertaken by an

external agency

• 1. THE APPENDIX OF SUBMISSIONS
• Varied in detail and evidence
• Minimum 5 submissions per region
• “Projects and Initiatives”
• Not subject to value judgments
• Often indicative of ‘whole system’ approach
• Template inevitably creates repetition – a price worth

paying

• Included some case studies

LEARNING FROM SUBMISSIONS

• The Submissions

– Speak for themselves – Evidence the criteria being met – Demonstrate progress across Wales and on many important fronts

• Case studies show how projects impact the lives of individuals

However, The submissions do not equate to categorical evidence that the ICF is achieving the required strategic shift in regional integrated working at the necessary scale and pace

• 2. THE FEATURES AND CHARACTERISTICS
• Illustrate that the primary aims of the ICF to obtain more

integrated working and an emphasis on prevention can be met in a variety of different ways, with different levels of funding and different lead agencies.

• The overall message from the projects listed is that there

is not a simple blueprint for addressing integration and prevention, or achieving good practice, but there are common features from which to learn.

• Consequently, there is not a single best way of using the

ICF and that is one of its strengths.

FEATURES AND CHARACTERISTICS (1)

The amount of funding attached to projects varies considerably

– Guidance does not stipulate funding bands – This assists a wide range of bids across the

• perational/strategic spectrum

– Difficult to assess whether the balance of small and large projects is right – Do they equate to the strategic shift desired?

FEATURES AND CHARACTERISTICS (2)

Some projects save money and some claim a return on investment

– Some explicit references to absence of savings not meaning absence of impact – Difficult to calculate savings e.g. different estimates of cost of NHS ‘bed day’ – Should the guidance be more explicit about VFM/ROI requirements?

FEATURES AND CHARACTERISTICS (3)

Projects are led by different agencies

– Different sectors – Demonstrates integrated approach – Should mixed market leadership be a requirement?

FEATURES AND CHARACTERISTICS (4)

Many projects demonstrate a key role for the Third Sector

– Encouraging in context of the Act – Does Third Sector involvement need to be an even stronger requirement?

FEATURES AND CHARACTERISTICS (5)

Projects can have a local and/or regional focus

– Demonstrates flexibility of ICF – Local projects often have more immediate impact – Are the local projects being used to achieve strategic shift in regional working? – How is learning applied across the region?

FEATURES AND CHARACTERISTICS (6)

A number of projects relate to step up/down facilities

– Not surprising – Intermediate Care Fund – Projects demonstrate integrated care as well as intermediate – Fund’s title misleading – Should step/down be mandatory requirement?

FEATURES AND CHARACTERISTICS (7)

A number of projects relate to the development of single points of access (SPoA)

– Presented as game changers in achieving integrated approach and care co-ordination – Should SPoA be a mandatory requirement?

FEATURES AND CHARACTERISTICS (8)

Some projects are regarded as forerunners to further growth and development

– Meets ICF requirement to build on good practice and increase scale of integration – Demonstrates ICF facility to provide ‘pump-priming’ – Are there enough pioneering projects? – Is risk sufficiently encouraged in the guidance? – Should learning be a requirement of all projects?

FEATURES AND CHARACTERISTICS (9)

Some projects are capacity or staff orientated

– ICF provides opportunity to increase capacity through new and additional services – Is there a difference between ICF objectives and core business? – Should guidance clarify that new and additional must always meet ICF principles?

FEATURES AND CHARACTERISTICS (10)

The ICF has been used to provide onward grants

– Leads to the creation of further projects – Is guidance sufficiently clear that grants must also meet ICF principles and objectives?

FEATURES AND CHARACTERISTICS (11)

The projects contain many references to projects supporting prevention through reablement

– Demonstrates the understanding to maintain independence and prevent escalation of need – Reflects specific reference to reablement in guidance – Supports recovery and recuperation – Are preventative services yet to be embedded as core services?

FEATURES AND CHARACTERISTICS (12)

Some projects are focused on the housing related aspects

• f achieving prevention and maintaining independence

– Aids and adaptations – Demonstrates benefits of capital element – Supports early hospital discharge – Reflects specific reference to housing in guidance – Reinforces importance of housing to prevention and independence

FEATURES AND CHARACTERISTICS (13)

Some projects are focused on strengthening community capacity to achieve prevention and maintain independence

– Adopts innovative strengths based approach – Organised via different agencies and different sectors – Should approach be more explicitly referred to in guidance?

FEATURES AND CHARACTERISTICS (14)

Some projects are focused on improving care pathways and providing clinical support to achieve prevention and maintain independence

– Clinical interventions important component of rapid response systems – Should guidance more clearly emphasise the benefits of multi- disciplinary approaches?

FEATURES AND CHARACTERISTICS (15)

Some projects have a strong focus on improving well- being

– Encouraging that well-being features given context of the Act – No specific reference to well-being in the guidance – Should guidance have more explicit references to the value of addressing well-being as a preventative initiative and to promote independence?

• 3. THE SECTION 3 EXAMPLES
• Demonstrate that to be successful, projects should

maintain an integrated focus, concentrate on measurable improvements for people and be part of a wider strategic effort to achieve change and improvement.

• An interesting area to explore further is how learning

from the evident success of relatively small scale, sometimes quite local projects, are being systematically used to influence strategic change across the region.

WHAT SECTION 3 TELLS US

How the criteria are being met in that projects:

• lead to improvements in the co-ordination of care
• lead to the development of new models of care
• assist in avoiding unnecessary hospital admissions and delayed discharges
• promote and maximise people’s independence
• support people’s recovery and recuperation
• encourage integrated working
• shift the way services are delivered and/or the ways the collaborating
• rganisations work
• provide a new or additional service
• deliver benefits and positive outcomes for older people.
• align with national and regional strategic priorities
• are well managed

• 4. THE EVALUATION REPORTS
• Adopt different reporting styles
• External evaluations provide useful learning points
• External evaluations refer to national research on factors

supporting intermediate care

– Overarching factors

• Focus on individuals
• Helpful legislative framework

– Service factors

• Clear care pathways

– Organisational

• Effective leadership and governance
• Culture of collaboration and learning

LEARNING FROM EVALUATION REPORTS

• Quarterly reports not best indicators of good practice
• Criteria and evaluation reports could be more closely

linked

• Greater conformity of reporting could assist learning
• Some missed opportunities to ‘tell the story’
• Is reporting too frequent?
• Lessons from external reports could be built into the

guidance

SOME CONCLUDING THOUGHTS

• Report is a review of good practice, not an evaluation
• Evidence of real progress on numerous fronts
• ICF is filling gaps and making a difference
• Many ICF funded services becoming core services
• Therefore, any threat to ICF becomes more serious year

by year

And finally……. Remember that whilst 40 swallows don’t make a summer they do indicate better times ahead!

Cardiff & Vale of Glamorgan Welsh Government Integrated Care Fund Learning Event

27th September 2017

Key Outcomes in 2016-17

Older People:

• 11,088 people were able to remain in their own homes
• 8,871 hospital admissions were prevented
• 2,923 hospital discharges were assisted
• 169 people were removed from the Delayed Transfer of Care list
• 1,550 bed days were saved (£426,250 cost saving)

Learning Disabilities / Children with Complex Needs:

• Initiation of the region-wide Disability Futures

Programme, an integrated approach working with housing, health, social care, education and third sector partners

• 11 projects focusing on ensuring integrated service

provision at key stages in the life of people with Learning Disabilities / Children with Complex Needs

• Over 745 people supported between Sep 2016 to March

2017

• 363 parents involved
• 297 people helped to access support in their home

communities

What’s worked well?

First Point

• f Contact

Cardiff-based telephone service facilitating access to preventative services and social care to improve independent living

• 1,550 bed days avoided
• £426,250 cost savings
• 116 patients removed

from Delayed Transfers

• f Care List
• 39 people provided

with step up / step down accommodation

• 96% of users felt able to

remain in their own home

Residential Discharge to Assess

Residential / nursing accommodation to expedite hospital discharge whilst patients continue to receive rehabilitation and assessment

• 48 adults received respite

care

• 14 people received complex

needs residential overnight respite

• 7 new carers secured to

support the adult placement scheme

• 100% received support

closer to home and proportionate to need

• 28,228 calls to the

service

• 72% of new cases

dealt with directly with no onward referral to adult services

• 95% of people felt

that their quality of life had been improved

Accommodation Solutions

Region-wide housing team to address individual housing needs. Includes provision of step up / step down accommodation and extended Rapid Response Adaptation Scheme

Bespoke Respite Care

Vale of Glamorgan - focused pilot service for people with Learning Disabilities

• 63 people provided

with re-ablement support in a nursing or residential home setting

• 54 people able to

return to their own home after receiving this service

• 95% bed utilisation rate

(Cardiff facility)

www.cvihsc.co.uk/about/what-we-do/rpb-annual-report

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.

What a very good idea this is, we love being in our home and most of all being independent

Challenges

• Funding uncertainty impacts upon:
• Service delivery;
• Staff development;
• Partnership working;
• Sustainability.
• Long term development.
• Scale and capacity to meet growing demand.
• Missed opportunities for alignment with other funding.

More information…

www.cvihsc.co.uk

Rhanbarth Cwm Taf Arian Gofal Integredig Cwm Taf Region Integrated Care Fund

Community Coordinators Cydlynwyr Cymunedol

• Initially to combat

isolation and loneliness in over 65’s

• Evolved to frail over

50’s

• Third Sector
• 5 coordinators
• 4 locality specific
• 1 Health
• Integrate Sectors
• Brwydro yn erbyn

arwahanrwydd ac unigrwydd pobl dros 65 i ddechrau

• Esblygu ar gyfer y

bregus dros 50

• Trydydd Sector
• 5 cydlynydd
• 4 penodol i’r ardal
• 1 Iechyd
• Integreiddio Sectorau

Health Coordinator Cydlynydd Iechyd

• GP Surgeries
• CIAS – Community

Integrated Assessment Service

• Stay Well@Home

Team

• Cwm Taf Health

Campaigns

• Meddygfeydd
• Gwasanaeth Asesu

Integredig Cymunedol

• Tîm Aros yn Iach

Gartref

• Ymgyrchoedd Iechyd

Cwm Taf

Locality Based Community Coordinators Cydlynwyr Cymunedol Wedi eu Lleoli yn y Gymuned

• Mapping/Gapping
• Community

Research

• Referrals
• Monitoring/Evaluati
• n
• Signposting
• Information

Bulletins

• Mapio / Bylchau
• Ymchwil Cymunedol
• Cyfeirio
• Monitro / Gwerthuso
• Arwyddbostio
• Bwletinau

Gwybodaeth

REFERRALS RECEIVED 1357 Referrals received 1357 Cyfeiriadau a dderbyniwyd 2016/2017 2016/2017

Signposts Arwyddbyst

3325 (2016/17) Signposts to

services and community groups Stroke Association Walking Groups Knitting Nanna’s Fibro Friends Young at Heart 50+ Forum Alzheimer’s Society Men’s Sheds Age Connects Morgannwg Bereavement Support Benefit/Energy advice

3325 (2016/17) Arwyddbyst at

wasanaethau a grwpiau cymunedol

Cymdeithas Strôc Grwpiau Cerdded Neiniau’n Gweu Ffrindiau Ffibro Ifanc o Galon Fforwm 50+ Cymdeithas Alzheimer’s Cwt Dynion Cyswllt Oedran Morgannwg Cefnogaeth Galar Budd / Cyngor Ynni

CASE STUDY ASTUDIAETH ACHOS

• GP Practice referral
• Mr and Mrs J were referred

for help for assisted refuse collection

• Identified that the couple

had multiple needs

• 6 organisations could offer

support.

• Mr and Mrs J chose to

accept some, but not all of the support.

• Cyfeirio o bractis Meddyg

Teulu

• Cafodd Mr a Mrs J eu

cyfeirio am help ar gyfer casglu sbwriel â chymorth

• Dynodwyd fod aml-

anghenion gan y cwpl

• Roedd 6 sefydliad yn gallu

cynnig cymorth

• Dewisodd Mr a Mrs J

dderbyn peth, ond nid yr holl gefnogaeth.

Y Her The challenge

• Pwysau’r gaeaf difrifol –

llif cleifion

• Rhyddhad gohiriedig
• Gwaith seilo
• Severe winter pressures
• patient flow
• Delayed discharges
• Silo working

Cam 1 – Mwy o Bresenoldeb Gofal Cymdeithasol mewn ysbytai Phase 1 – Increased Social Care Presence in hospitals

• Wedi symud pwynt

mynediad sengl i mewn i’r ysbyty gan ddefnyddio cydgysylltwyr rhyddhau

• Swyddi Gwaith

Cymdeithasol wedi’u hapwyntio gyda chyswllt ag Ysbytai Cymunedol

• Cysylltiadau sefydlog rhwng

ALl a’r staff yn yr ysybtai

• Cyfathrebiad gwell rhwng

iechyd a gofal cymdeithasol

• Moved single point of

access into hospital using discharge coordinators

• Appointed Social Work

posts linked to Community Hospitals

• Built relationships between

LA & hospital based staff

• Improved communication

between health & social Care

Canlyniadau Cam 1 Outcomes of Phase 1

Cyfathrebiad gwell rhwng Iechyd a Gofal Cymdeithasol wedi arwain at:-

• Lleihad mewn niferoedd

cyffredinol rhyddhad gohiriedig

• Llif Cleifion mwy

effeithlon gan ddefnyddio gwybodaeth gyfredol Improved communication between Health & Social Care Services led to:-

• A reduction in the
• verall numbers of

delayed discharges

• Patient flow more

efficient using up to date information

Cam 2 Cydestun am newid Phase 2 Context for change

Gwersi a ddysgwyd:

• Cydweithio’n digwydd pan fydd pobl

yn mynychu D&AB neu wedi bod yn yr ysbyty fel claf mewnol sydd angen cymorth iechyd a/neu

• fal

cymdeithasol yn y gymuned ar ôl cael eu rhyddhau

• Cyfathrebiad

gwell rhwng staff Iechyd a Gofal Cymdeithasol yn ystod cynllunio rhyddhad yn gwella llif cleifion

• Mynediad i becynnau gofal y tu allan

i oriau craidd yn atal mynediad i ysbyty diangen Lessons learnt :

• Joint working happens when people

attend A & E or have been hospitalised and require community health and/or social care support on discharge

• Improved communication between

Health & Social Care staff during discharge planning improves patient flow.

• Access to packages of care out of

core hours prevents unnecessary hospital admissions.

Aros yn well yn y Cartref Stay Well @Home

Amcan

• Cefnogi gwasanaethau ar y cyd,

gan ddarparu mynediad cyflym a thriniaeth effeithiol

• Parchu dewis cleifion a chynnwys

cleifion a gofalwyr yn y broses rhyddhau o’r ysbyty

• Hyrwyddo annibyniaeth, adfer a

chynhwysiant cymdeithasol Aim

• To support joined up services,

providing fast access and effective treatment

• To respect patients’ preferences

and involve patients and carers in hospital discharge

• To

promote independence, recovery and social inclusion.

Gwasanaeth Aros yn well yn y cartref Stay Well @home Service

• Tîm ysbyty aml-ddisgyblaethol:
• Gweithwyr Cymdeithasol
• Therapyddion Galwedigaethol
• Ffisiotherapyddion
• Technegwyr Therapi

Wedi'i leoli mewn adrannau Damweiniau ac Achosion Brys, 8 am. - 8 pm. 365 diwrnod y flwyddyn.

• Ymgymryd ag asesiadau cymesur mewn

wardiau damweiniau ac achosion brys a wardiau ysbytai er mwyn osgoi derbyn cleifion diangen a rhyddhau cleifion i wasanaethau priodol

• Comisiynu amrywiaeth o ymatebion yn y

gymuned:

• Pecynnau gofal
• Cefnogaeth nyrsio
• Asesiad Meddyginiaeth
• Multidisciplinary hospital based team:

– Social Workers – Occupational Therapists – Physiotherapists – Therapy Technicians Based at A & E departments, 8 am. – 8

• pm. 365 days a year.
• Undertake proportionate assessments at

A & E and hospital wards to avoid unnecessary hospital admissions and discharge patients to appropriate services

• Commission a range of community based

responses: – Packages of care – Nursing support – Medication Assessment

Data Cychwynnol Initial Data

Mae'r ddata o’r dri mis cyntaf yn awgrymu;

• Cynnydd mewn cleifion dros 61

mlynedd gyda sero HYA

• Cynnydd mewn cleifion dros 61
• ed gyda HYA 1-5 diwrnod
• Gostyngiad mewn cleifion dros 61

mlynedd yn aros am fwy na 5 diwrnod

• Gostyngiad cyffredinol mewn

HYA ar gyfer y rheiny sydd â HYA >5 diwrnod

First three months of data suggest;

• An increase in patients over

61 years with zero LOS

• An increase in patients over

61 years with 1-5 days LOS

• A reduction in patients over

61 years admitted for longer than 5 days

• An overall reduction in LOS

for those that have a >5 day LOS

Shelley Welton and Kemmine Compere

Shelley Welton a Kemmine Compere

Project Overview:

• Roots in My Day, My Life
• Research and piloting
• Facilitation not support
• Information and advice
• Membership led; co-production.

Trosolwg o’r Prosiect:

• Gwreiddiau yn Fy Niwrnod, Fy Mywyd
• Ymchwil a pheilota
• Hwyluso nid cefnogaeth
• Gwybodaeth a chyngor
• Arweinir gan aelodau; cydgynhyrchu

Objectives of

My Mates aims:

• To provide opportunities for adults with a learning disability

to form friendships and relationships in a supportive environment

• To build confidence and independence through networks and

community

• To improve awareness and education about relationships for

people with a learning disability Expected Outcomes:

• People will have friends and an active social life
• People will have greater opportunities to form deeper, more

exclusive relationships

• People will find networks of support which are more natural

and sit outside of services

Amcanion

Nodau My Mates:

• I roi cyfleoedd i oedolion sydd ag anableddau dysgu ffurfio

cyfeillgarwch a pherthnasau mewn amgylchedd cefnogol

• I fagu hyder ac annibyniaeth trwy rwydweithiau a’r gymuned
• I wella ymwybyddiaeth ac addysg am berthnasau ar gyfer

pobl sydd ag anabledd dysgu Deilliannau Disgwyliedig:

• Bydd gan bobl gyfeillion a bywyd cymdeithasol bywiog
• Bydd gan bobl gyfleoedd mwy i ffurfio perthnasau dwysach a

mwy detholedig

• Bydd pobl yn dod o hyd i rwydweithiau cefnogi sy’n fwy

naturiol ac sy’n eistedd y tu allan i wasanaethau

So what is

• Processed nearly 100 formal applications to become members.
• Facilitated 30 social events ranging from meals, theatre trips, days out

and balls since April 2016. Uptake has been very high.

• 98 people bought tickets and attended the Christmas Glitter Ball at the

Celtic Manor on 14th December 2016. Fantastic feedback received.

• Established a base for members to access confidential conversations if

desired.

• The team is C-Card registered and trained to deliver workshops.
• The team has created working relationships and is accessible across

Gwent (Councils, People First, voluntary agencies and providers).

• Well established Facebook and Twitter accounts used daily by My

Mates members.

Felly beth yw

• Proseswyd bron 100 o geisiadau ffurfiol i ymaelodi.
• Hwyluswyd 30 o ddigwyddiadau cymdeithasol o brydau o fwyd, teithiau i’r

theatr, diwrnodau allan a dawnsiau ers mis Ebrill 2016. Derbyniwyd lefel uchel

• ymateb.
• Prynwyd tocynnau a mynychwyd Dawns Glitter y Nadolig yng Ngwesty’r Celtic

Manor ar 14eg Rhagfyr 2016 gan 98 o bobl. Derbyniwyd adborth rhagorol.

• Sefydlwyd lleoliad i aelodau gael mynediad i drafodaethau cyfrinachol pe

dymunent.

• Mae gan y tîm gofrestriad C-Card ac maent wedi’u hyfforddi i ddarparu

gweithdai.

• Mae’r tîm wedi creu perthnasau gwaith ac mae’n hygyrch i bawb yn ardal

Gwent (Cynghorau, Pobl yn Gyntaf, asiantaethau a darparwyr gwirfoddol).

• Cyfrifon Facebook a Twitter wedi’u hen sefydlu a chânt eu defnyddio bob dydd

gan aelodau My Mates.

What does cost?

1 x fte Co-ordinator

Promotion/ Supplies

2 x 0.4 Facilitators

ICF Funding £50.000

Beth yw cost ?

1 x Cydlynydd amser llawn cyfatebol

Hyrwyddo/ Deunyddiau

2 x 0.4 Hwylusydd

Ariannu Cronfa Gofal Integredig £50,000

Benefits of [X]

 People are creating friendships/relationships and the opportunity to have an active social life.  People are finding networks of support which are more natural and sit outside of services.  Reliance upon paid staff members is and will continue to decrease.  Advice and information is available to members to promote health-care, self-care and safety.  My Mates members are actively engaging with the team and bringing forward ideas for the future.

Buddion

 Mae pobl yn creu cyfeillgarwch/perthnasau ac yn cael cyfle i brofi bywyd cymdeithasol bywiog.  Mae pobl yn dod o hyd i rwydweithiau a chefnogaeth sy’n fwy naturiol ac sy’n eistedd y tu allan i wasanaethau.  Mae’r dibynadwyedd ar staff cyflogedig yn gostwng a bydd yn parhau i ostwng.  Mae cyngor a gwybodaeth ar gael i aelodau o ran hyrwyddo gofal iechyd, hunan-ofal a diogelwch.  Mae aelodau My Mates yn ymgysylltu’n weithredol gyda’r tîm ac yn cynnig syniadau ar gyfer y dyfodol.

Benefits of

Buddion

Benefits of

Example 1: Improving Relationships with Providers

Buddion

Enghraifft 1: Gwella perthnasau gyda darparwyr

Benefits of

Example 2: Supporting My Mates members to build confidence

 Personal presentation

and self-worth

 Body language  Supporting others  Choices  Increased social network  Increased community

presence

Buddion

Enghraifft 2: Cefnogi aelodau My Mates i fagu hyder

 Cynrychiolaeth bersonol

a hunan-werth

 Iaith y corff  Cefnogi pobl eraill  Dewisiadau  Rhwydwaith

cymdeithasol mwy

 Presenoldeb mwy yn y

gymuned

• Managing demand
• Expectations of

support

• Paying for events
• Workshops
• Dating
• Holds true to the

philosophy

• Supports people to

consider new and different approaches

• Develops a range of
• ptions
• Takes an iterative

approach; learning as we go along

Overcoming obstacles

• Rheoli galw
• Disgwyliadau o ran

cymorth

• Talu am

ddigwyddiadau

• Gweithdai
• Canlyn
• Glynir at yr

athroniaeth

• Cefnogir pobl i ystyried

dulliau newydd a gwahanol

• Datblygir ystod o
• psiynau
• Cymerir ymagwedd

ailadroddol; dysgu wrth i ni fynd ymlaen

Goresgyn rhwystrau

What would you do differently?

• One team approach
• Pilot it in a ‘less developed’

area

• Less large group activities;

focus on personal relationships rather than group friendships

• Not worry so much about

what people might think!

What would you repeat?

• Staff team – 100%
• The model – our approach

to facilitating relationships

• Having a brand, marketing
• Our approach to ‘easing
• ut’

Lessons Learned

Beth fyddech yn ei wneud yn wahanol?

• Ymagwedd un tîm
• Cynnal cynllun peilot mewn

ardal ‘llai datblygiedig’

• Llai o weithgareddau ar

gyfer grwpiau mawr; canolbwyntio ar berthnasau personol yn hytrach na chyfeilgarwch grŵp

• Peidio â phoeni cymaint am

beth fydd pobl yn ei feddwl!

Beth fyddech chi’n ei ailadrodd?

• Tîm y staff – 100%
• Y model – ein dull ar gyfer

hwyluso cyfeillgarwch

• Bod â brand, marchna
• Ein hymagwedd at

‘ymlithro’

Gwersi a ddysgwyd

Spreading Success Rolling out My Mates across Gwent

• Identifying advocates for My Mates in other

areas

• Managing demand carefully and incrementally

Significant levels of interest across the UK

• Potential for partnerships
• Potential for other areas to replicate the

model

Lledu llwyddiant Cyflwyno cynllun My Mates ar draws Gwent

• Adnabod eiriolwyr ar gyfer My Mates mewn

ardaloedd eraill

• Rheoli’r galw yn ofalus ac yn gynyddrannol

Lefelau sylweddol o ddiddordeb ar draws y DU

• Potensial i greu partneriaethau
• Potensial i ardaloedd eraill atgynhyrchu’r

model

Everybody should do this…

Dylai pawb wneud hyn…

Further Information

Contact Information:

 Shelley Welton: shelleywelton@monmouthshire.gov.uk  Kemmine Compere: kemminecompere@monmouthshire.gov.uk

Follow us on Twitter: @MCCMyMates 01873 735414

Gwybodaeth bellach

Manylion cyswllt:

 Shelley Welton: shelleywelton@monmouthshire.gov.uk  Kemmine Compere: kemminecompere@monmouthshire.gov.uk

Dilynwch ni ar Twitter: @MCCMyMates 01873 735414

Digwyddiad Dysgu ICF (Caerdydd) / ICF Learning Event (Cardiff) 27ain Medi 2017/27th September 2017

Nicola Stubbins – Noddwr Arweiniol ICF, Cyfarwyddwr Corfforaethol: Cymunedau / ICF Lead Sponsor, Corporate Director: Communities Sharon Hinchcliffe – Rheolwr Prosiect Gwasanaethau Integredig/ Project Manager Integrated Services

www.cydweithredfagogleddc ymru.cymru /

Beth ydym ni wedi bod yn ei wneud? What have we been doing?

• Adeiladu Cymunedau a

Chydlynu Ased Lleol

– Cael ei adnabod yn genedlaethol gan Iechyd Cyhoeddus Cymru - wedi’u cynnwys yn eu catalog o arferion da mewn dulliau ar sail ased a chyd-gynhyrchu.

• Cefnogi Cynnydd

– Asesiad o sgiliau byw'n annibynnol pobl - galluogi comisiynu gwasanaethau gyda dealltwriaeth well ei angen o sgiliau byw'n annibynnol unigolyn.

• Building Communities

and Local Asset Co-

• rdination

– Recognised nationally by Public Health Wales - included in their catalogue of good practice in asset based approaches and co- production

• Progression Support

– Assessment of peoples independent living skills – enabling commissioning of services with an improved understanding of a person’s independent living skills needed.

www.cydweithredfagogleddc ymru.cymru /

Adeiladu Cymunedau Building Communities

• Beth yw’r prosiect?
• Cyfle i ‘ddatblygu prosiect

cyd-gynhyrchu a phroses, a fydd yn galluogi sefydliadau partner i weithio gyda’i gilydd gyda phobl sy’n byw yn ein cymunedau i fyw eu bywydau y maent eisiau’ ac i fynd i’r afael â’r anghydbwysedd rhwng y defnyddiwr a’r darparwr.

• What is the project?
• An opportunity to ‘develop

a co-production project, and process, which will enable partner

• rganisations to work

together with the people living in our communities to live the lives that they want’ and to address the imbalance between user and provider

www.cydweithredfagogleddc ymru.cymru /

Adeiladu Cymunedau Building Communities

• Beth mae arnom ni eisiau ei

gyflawni?

• Bwriad y prosiect yw ymgynghori ar

ystod o wasanaethau mewn maes penodol ac ymchwilio sut y gallwn ddefnyddio'r asedau o fewn ein cymunedau i ddatblygu gwydnwch a hunan gynhaliaeth.

• Uwchlaw popeth roedd y model yn

gobeithio sefydlu ffordd newydd o weithio a fyddai'n cael ei ddyblygu

• Drwy weithio mewn partneriaeth i

sefydlu Bwrdd Ymgynghori ac Ymgysylltu ar y Cyd, ac wedi mabwysiadu model Adeiladu Cymunedau, fel ei ffordd gynhwysfawr o ymgysylltu â chymunedau.

D.S. Mabwysiadwyd gan y Bwrdd Gwasanaeth Cyhoeddus fel model cydnabyddedig o arferion da mewn cymunedau sy’n ymgysylltu

• What did we want to achieve?
• The project aimed to consult on a

range of services in a specific area and explore how we could use the assets within our communities to develop resilience and self – sufficiency

• Above all the model hoped to

establish a new way of working that would be replicated

• Through partnership working

establish a Joint Engagement and Consultation Board, and adopted the Building Communities model as its comprehensive way of engaging with communities.

N.B. Adopted by the Public Service Board as a recognised model of good practice in engaging communities

www.cydweithredfagogleddc ymru.cymru /

Adeiladu Cymunedau Building Communities

• Sut gwnaethom ni hyn?
• Ymgynghoriad dwys,

ymgysylltu wedi’i dargedu

• Sgyrsiau cadarnhaol yn

canolbwyntio ar beth oedd cymunedau eu hangen

• Sefydlu grŵp tasg a gorffen

wedi’i arwain gan aelodau

• 'r gymuned a'i gefnogi gan

y strwythur Alliance cyffredinol

• How did we do it?
• Extensive consultation,

targeted engagement

• Positive conversations

focussed on what communities needed

• Set up task and finish group

led by community members and supported by the

• verall Alliance structure

www.cydweithredfagogleddc ymru.cymru /

Adeiladu Cymunedau Building Communities

• Beth sydd wedi cael ei gyflawni?
• Mae Alliance yng ngrŵp sefydledig gyda’i gyfrif banc ei

hun erbyn hyn

• Mae’r grŵp wedi dechrau edrych ar sefydlu cymuned

sy’n Gyfeillgar i Ddementia a’r posibilrwydd o gomisiynu ei wasanaethau gofal dydd ei hun drwy’r canolfannau, bydd unrhyw refeniw a gynhyrchir yn cael ei roi’n ôl i Alliance.

• Rôl Cydlynwyr Asset lleol yn cael eu hariannu gan

Awdurdod Lleol mewn canolfannau cymunedol, yn gyfrifol am ganmol yr agenda lles y model Adeiladu Cymuned, drwy helpu preswylwyr sydd wedi’u hynysu’n gymdeithasol i ailgysylltu â’u cymunedau. Model unigryw, llwyddiant yn golygu cyflogi 2 LAC yn y gymuned

• Mae’r model Adeiladu Cymunedau yn pwysleisio ar

gydgynhyrchiad a amlygwyd fel model o arferion da. Mae Iechyd Cyhoeddus Cymru yn darparu cyllid hwyluso

• £2500 y flwyddyn i ddyblygu’r model.
• Angen a nodwyd i ddeall yn well rôl/ cyfrifoldeb

Cynghorwyr Tref a Chymuned. Cyllid wedi’i ddiogelu ar gyfer prosiect i gyflogi Swyddogion Ymgysylltu â’r Gymuned, sydd â’r dasg o gyflwyno prosiect Adeiladu Cymunedau mewn 8 ardal, wedi ymgysylltu â 2400 o bobl ac wedi dynodi asedau, bylchau a blaenoriaethau i'w symud ymlaen maes o law.

• What’s been achieved?
• Alliance is now a constituted group with it’s own bank

account

• The group has begun looking at establishing a Dementia

Friendly community and potential of commissioning its

• wn day-care services through the hubs, any revenue

generated put back into Alliance

• Local Asset co-ordinators role funded by LA based in

community hubs, responsible for complimenting the well-being agenda of the Building Community model through reconnecting socially isolated residents with their communities. Bespoke model, success meant employment of 2 more community based LAC’s.

• The Building Communities model emphasis on co-

production highlighted as model of good practice. Public Health Wales provides a facilitation fund of £2500 per year to replicate the model

• Identified need for better understanding of

role/responsibility of Town & Community Councillors. Secured funding for project to employ Community Involvement Officers, tasked with rolling out Building Communities project in 8 areas , has engaged with 2400 people and identified assets, gaps and priorities to take forward in due course.

www.cydweithredfagogleddc ymru.cymru /

Adeiladu Cymunedau Building Communities

www.cydweithredfagogleddc ymru.cymru /

• nd diolchodd am y wybodaeth

Adeiladu Cymunedau Building Communities

• Beth wnaethom ni ei

ddysgu?

• Amser ac Adnoddau
• Prynu gan bartneriaid
• Rhaid i’r broses fod yn

ystyrlon

• Cynghorau Tref a

Chymuned yn rhan o hyn o'r dechrau

• Nid oedd grwpiau tasg a

gorffen wedi gweithio

• What did we learn?
• Time & Resource
• Buy in from partners
• The process must be

meaningful

• Town & Community

Councils involved from beginning

• Task and finish groups

didn’t work

www.cydweithredfagogleddc ymru.cymru /

Cefnogi Cynnydd Progression Support

• Beth yw’r prosiect?

– Cymorth tymor byr i helpu unigolion gyflawni eu canlyniadau lles personol – Cefnogi sefydlu tîm amlddisgyblaethol h.y. Therapi Galwedigaethol a staff cefnogi cynnydd uniongyrchol.

• What is the project?

– Short term support to help individuals achieve their personal well-being

• utcomes

– Support the establishment of a multi- disciplinary team i.e. Occupational therapy and direct progression support staff

www.cydweithredfagogleddc ymru.cymru /

Cefnogi Cynnydd Progression Support

• Beth mae arnom ni eisiau ei

gyflawni?

– Annog annibyniaeth, cynyddu hyder a hunanwerth gan ddefnyddio gweithgareddau dyddiol ystyrlon. – Gwella cyfranogiad cymunedol/ lleihau anwahanrwydd cymdeithasol – Lleihau pwysau ar ofalwr/ staff cymorth/ gwasanaethau statudol drwy sefydlu dull sydd yn canolbwyntio ar gynnydd a chyflawni’r canlyniadau a gytunwyd. – I ddatblygu adnodd gallu gwell i staff weithio ochr yn ochr â GC, ThG, Staff nyrsio a darparwyr cyfredol.

• What did we want to achieve?

– Encourage independence, increase confidence and self-value using meaningful everyday activities – Improve community participation / reduce social isolation – Reduce reliance on carer / support staff / statutory services by establishing an approach that focuses on progression and the achievement of agreed

• utcomes

– To develop an enhanced enablement staff resource to work alongside existing SW, OT, Nursing staff and providers.

www.cydweithredfagogleddc ymru.cymru /

Cefnogi Cynnydd Progression Support

• Sut gwnaethom ni hyn?
• Llunio ffurflen atgyfeirio newydd, hanfodol

bod unigolyn eisiau dysgu sgil newydd a bydd hyn yn diwallu eu canlyniad lles personol.

• Cynllun cymorth cynnydd unigol wedi’i

gwblhau sydd yn galluogi staff cefnogi cynnydd i gefnogi’r unigolyn yn briodol gyda thasgau corfforol a llafar.

• Cynlluniau cynnydd yn cael eu hadolygu’n

rheolaidd am dystiolaeth i gyflawni amcanion a chanlyniadau personol.

• Ar ôl cyrraedd dy nod, cyfle i osod un arall os

yw’r unigolyn wedi adnabod un

• Cyfle i staff cefnogi cynnydd i rannu eu

gwybodaeth a sgiliau i asiantaethau gofal eraill i sicrhau trosglwyddiad esmwyth o un tîm staff i un arall.

• How did we do it?
• Designed new referral form, essential that

person wants to learn new skill and this will meet their personal well-being outcome

• Individual progression support plan

completed which enables the progression support staff to appropriately support the person with physical and verbal promoting for tasks

• Progression plans reviewed regularly for

evidence of achieving personal goals and

• utcomes
• Once goal reached opportunity to set

another one if identified by person

• Opportunity for progression support staff to

handover their knowledge and skills to other care agencies to ensure smooth transition from one staff team to another

www.cydweithredfagogleddc ymru.cymru /

Cefnogi Cynnydd Progression Support

• Beth sydd wedi cael ei

gyflawni?

• Ailwampio adeilad i ddarparu

Canolfan Adnodd Anableddau

• Cyfle i geisio byw'n annibynnol
• Defnyddio teleofal o fewn y

broses

• Seibiant i ofalwyr
• Cyswllt posibl gyda choleg lleol

i ddarparu Cwrs Byw'n Annibynnol

• Ystafell Synhwyraidd newydd,

trafodaeth gyda phartneriaid Nam Ar o’r Synhwyrau y 3ydd sector.

• What’s been achieved?
• Refurbished building to

provide Disabilities Resource Centre

• Opportunity to try

independent living

• Use of telecare within the

process

• Respite for carers
• Potential link with local college

providing Independent Living Course

• New Sensory room, in

discussion with 3rd Sector Sensory Impairment partners

www.cydweithredfagogleddc ymru.cymru /

Cefnogi Cynnydd Progression Support

Dave - Dave was referred to us for travel training to and from Denbigh to Rhyl to attend Buzz Club. We started week 1 with 1:1 support to catch the bus, walk to Buzz, then catch the bus home at the right time and walk home. Week 2 I supported Dave to catch the bus but I waited in Rhyl for him to arrive. He arrived at Buzz Club with no

• prompts. Week 3 I met Dave at Buzz Club

and week 4 I just observed him getting off the bus to go home. This was done within 4 weeks with excellent results. Dave still attends Buzz.

www.cydweithredfagogleddc ymru.cymru /

Dave – Atgyfeiriwyd Dave atom ni ar gyfer hyfforddiant teithio i Ddinbych ac oddi yno i'r Rhyl i fynd i'r Clwb Buzz. Fe wnaethom ddechrau wythnos 1 gyda chefnogaeth 1:1 i ddal y bws, cerdded i Buzz, yna dal y bws adref ar yr amser cywir a cherdded adref. Wythnos 2 - Fe wnes i gefnogi Dave i ddal y bws ond fe wnes i aros yn y Rhyl iddo gyrraedd. Fe gyrhaeddodd y Clwb Buzz heb unrhyw anogiadau. Wythnos 3 – Fe wnes i gyfarfod Dave yn y Clwb Buzz ac yn ystod wythnos 4 dim ond arsylwi arno’n mynd oddi ar y bws am adref wnes i. Cafodd hyn ei wneud o fewn 4 wythnos gyda chanlyniadau ardderchog. Mae Dave yn dal yn mynd i Buzz.

Canlyniadau ac Adrodd Rhanbarthol Regional Reporting & Outcomes

• Gwaith pellach sydd i’w wneud:

– Prosiectau Pobl Hŷn a Bregus 50+ – Prosiectau AD a PAD a Gofalwyr 40+ – 10 Prosiect Cyfalaf

• Gwaith rhagorol yn cychwyn i

wella adrodd gan ddefnyddio’r templed newydd Mae’n ddyddiau cynnar ar gyfer y flwyddyn drosiannol hon, fodd bynnag, mae ychydig o gynnydd da i adnabod a chytuno ar ganlyniadau a mesurau ar y cyd ar draws y rhanbarth, gyda gweithdai pellach wedi’u trefnu i gadw’r momentwm.

• Further work to be done:

– 50+ Frail and Older People projects – 40+ LD & CCN and Carers projects – 10 Capital projects

• Excellent work underway to

improve reporting using the new

• template. It’s early days in this

transitional year, however, some very pleasing progress in identifying and agreeing joint

• utcomes and measures across

the region with further workshops planned to keep up momentum.

www.cydweithredfagogleddc ymru.cymru /

Welsh Government Learning Event Intermediate Care Fund Powys 2016-17

Digwyddiad Dysgu Llywodraeth Cymru Cronfa Gofal Canolradd Powys 2016-17

Assistive Technology

Supporting unpaid carers through the use of assistive technology equipment

Technoleg Gynorthwyol

Cefnogi gofalwyr di-dâl trwy’r defnydd o gyfarpar technoleg gynorthwyol

Assistive Technology

• Created a demonstration and training facility

within a sheltered accommodation block centrally located in mid Powys. The facility is a 2 bedroom flat which has been kitted out with large range of stand-alone assistive technology products as well as a wide range of telecare sensors designed to manage a number of personal and environmental risks

• 9 open days which was attended by 77 people,

including staff, members of the public and County Councillors

Technoleg Gynorthwyol

• Cyfleuster hyfforddi ac arddangos wedi’i greu o fewn bloc llety lloches a leolir

yn ganolog yng nghanol Powys. Fflat 2 ystafell wely yw’r cyfleuster sy’n cynnwys ystod eang o gynnyrch technoleg gynorthwyol unigol ynghyd ag amrywiaeth eang o synwyryddion teleofal i reoli nifer o beryglon personol ac amgylcheddol

• 9 diwrnod agored a fynychwyd gan 77 o bobl, gan gynnwys staff, aelodau’r

cyhoedd a Chynghorwyr Sir

• Yn ychwanegol at hyn, fe wnaethom ddarpariaeth trwy apwyntiad ar gyfer

timoedd staff ehangach gan gynnwys: Staff Therapi Galwedigaethol, Ailalluogi, Gofal Cartref Mewnol, Gofal Integredig, Broceriaeth a Llinell Uniongyrchol Powys

• Hyfforddiant o fewn ystafell ddosbarth wedi’i atgyfnerthu gan hyfforddiant

ymarferol o fewn fflat arddangos gyda 22 o Aseswyr wedi’u hyfforddi ynghyd â 44 o aelodau staff ar draws sefydliadau statudol, y trydydd sector a’r sector preifat

• Modiwl e-ddysgu wedi’i ddatblygu sy’n rhoi sylfaeni cryf i ni, ochr yn ochr â’r

fflat arddangos, i barhau gyda’r rhaglen hyfforddi

Assistive Technology

• Baseline: Support 40 unpaid carers
• Actual: 85 unpaid carers supported
• 134 items of equipment issued
• 16 products identified which could assist/ease the pressure on unpaid carers in relation

to the following risks and issues as well as easing pressure on them:

• Avoidance of falls or mitigating the effect of a fall through early indication and alert
• Wandering
• Avoidance of missing person incidents
• Reminding
• Remote Monitoring
• Reassurance
• Independence
• Outcomes for the cared for:
• Avoidance / delay in admission to a care home
• Avoidance of unplanned hospital admissions
• Reduction in the demand for respite interventions

Technoleg Gynorthwyol

• Gwaelodlin: Cefnogi 40 o ofalwyr di-dâl
• Gwirioneddol: Cefnogi 85 o ofalwyr di-dâl
• 134 eitem o gyfarpar wedi’u cyflwyno
• Dynodwyd 16 o gynnyrch a allai gynorthwyo/lleddfu’r pwysau ar ofalwyr di-dâl o ran y

peryglon a’r materion canlynol ynghyd â lleddfu’r pwysau arnynt hwy:

• Osgoi achosion o gwympo neu leddfu effeithiau cwympo trwy waith adnabod a

rhybuddio cynnar

• Crwydro
• Osgoi achosion o unigolion ar goll
• Atgoffa
• Monitro o Bell
• Rhoi Sicrwydd a Chysur
• Annibyniaeth
• Deilliannau ar gyfer y sawl sy’n derbyn gofal:
• Osgoi/oedi wrth gael eu derbyn i mewn i gartref gofal
• Osgoi ymweliadau heb eu cynllunio lle derbynnir unigolion i’r ysbyty
• Gostyngiad yn y galw am ymyriadau seibiant

Assistive Technology

• 80 year old gentleman in later stages of dementia

living alone

• Started to wander and whilst this stopped for a

while he was found walking his dog in the early hours of the morning, in his dressing gown, the temperature was -6°C

• Admission to nursing home looked to be

inevitable and whilst the family accepted this, they were open to use of assistive technology

Technoleg Gynorthwyol

• Gŵr 80 mlwydd oed gyda dementia yn ei gamau

hwyraf ac yn byw ar ben ei hunan

• Dechreuodd grwydro ac er i hyn beidio am

ychydig, cafodd ei ganfod yn cerdded ei gi yn

• riau mân y bore, yn ei ŵn llofft, pan oedd y

tymheredd yn -6°C

• Roedd cael ei dderbyn i gartref nyrsio yn edrych i

fod yn anochel a thra bod ei deulu yn derbyn hyn, roeddent yn agored i’r defnydd o dechnoleg gynorthwyol

• rhaglennu’r

i’w

Assistive Technology

• Elderly lady recently widowed, suffering with

episodes of psychotic depression out and struggling to cope by herself

• Had periods of hospital admission despite

reablement intervention/support

• Son was main carer and lived close by but did not

want a home care package as he felt this would make his mother dependent

• A telephone with a pendant alarm and Canary

Technoleg Gynorthwyol

• Hen wraig sydd wedi colli ei gŵr yn ddiweddar,

ac yn dioddef o bennodau o iselder seicotig gan gael trafferth i ymdopi ar ei phen ei hunan

• Wedi cael cyfnodau o gael ei derbyn i’r ysbyty er

gwaethaf ymyrraeth/cefnogaeth gan y tîm ailalluogi

• Ei mab oedd ei phrif ofalwr ac roedd yn byw

gerllaw ond nid oedd eisiau pecyn gofal cartref gan ei fod yn teimlo y byddai’n gwneud ei fam yn

• ŷ
• i’r

a’i

Assistive Technology

• Elderly gentleman with dementia who enjoys

walking

• Wife and daughter increasingly worried about

whereabouts as he has lost his ability to use a mobile phone

• Family want him to continue to go for his daily

walks independently and not be forced to go a certain way every time as he enjoys the freedom and adventuring

Technoleg Gynorthwyol

• Gŵr oedrannus gyda dementia sy’n mwynhau

cerdded

• Roedd ei wraig a’i ferch yn gynyddol bryderus am

le’r oedd yn mynd gan ei fod wedi colli’r gallu i ddefnyddio ffôn symudol

• Mae’r teulu eisiau iddo barhau i fynd am dro yn

ddyddiol ac yn annibynnol ac iddo beidio â chael ei orfodi i fynd ffordd benodol pob tro gan ei fod yn mwynhau’r rhyddid ac anturiaethau

• ŵr

parhau’n gyda’r

• petai’n

neu’n

Assistive Technology

What is the Impact for Unpaid Carers?

“The Canary System was fantastic!

I could keep an eye on mum’s movements and use that knowledge to inform the CPN of what was going

• n when she was by herself. I was

much less anxious about having the ability to log into the system and see that mum was ok” “It allows me to leave my husband at one end of the house while I am in the kitchen or garden” “I just wanted to pass on that Mr and Mrs R and their daughter all think that the GPS tracker is

• fantastic. They explained that Mr R

returned from a walk recently with cuts all down his leg and couldn’t remember what happened but thought he must have “had a stumble” They all agreed that this must have been more than “a stumble” but all felt relived that should he have been unable to return after the fall/stumble, then they would have been able to find

• ut where he was”

Technoleg Gynorthwyol

Beth yw’r Effaith ar gyfer Gofalwyr Di-dâl?

“Roedd y System Canary yn wych!

Gallwn gadw golwg ar symudiadau mam a defnyddio’r wybodaeth honno i ddweud wrth y Nyrs Seiciatryddol Gymunedol am yr hyn oedd yn digwydd pan yr oedd ar ei phen ei

• hunan. Roeddwn yn llawer lIai

pryderus wrth allu mewngofnodi i’r system a gweld bod mam yn iawn” “Mae’n caniatáu i mi adael fy ngŵr mewn un pen o’r tŷ tra byddaf yn y gegin neu’r ardd” “Roeddwn i ond eisiau trosglwyddo’r neges fod Mr a Mrs R a’u merch yn meddwl fod y cyfarpar tracio GPS yn

• wych. Fe wnaethant esbonio fod Mr

R wedi dychwelyd o fod am dro yn ddiweddar gyda briwiau ar ei goes

• nd nad oedd yn gallu cofio beth

ddigwyddodd gan dybio fodd bynnag ei fod wedi “baglu a chwympo”. Cytunon nhw i gyd ei fod yn fwy na “baglu a chwympo” ond roeddent yn teimlo rhyddhad y gallent fod wedi canfod lle yr oedd petai heb allu dychwelyd wedi iddo faglu/cwympo”

Challenges

Challenge Response Number of Projects Condense number and focus on key themes giving us a more strategic approach Understanding the impact of projects on whole system outcome Continuing to work with and challenge project leads requesting better evidence

• f outcomes and the impact on

individuals as well as the need to support the “case” for mainstream

• funding. Use of examples of good

practice. Multiple reporting requirements to different stakeholders Harmonisation of reporting within our control to meet local and Welsh Government requirements

Heriau

Her Ymateb Nifer y Prosiectau Crynhoi’r nifer a chanolbwyntio ar y prif themâu gan roi dull mwy strategol i ni Deall effaith prosiectau ar ddeilliannau’r system gyfan Parhau i weithio gydag arweinyddion prosiectau a’u herio gan ofyn am well dystiolaeth o ddeilliannau a’r effaith ar unigolion ynghyd â’r angen i gefnogi’r “achos” dros nawdd prif ffrwd. Defnyddio enghreifftiau o arfer da. Gofynion adrodd niferus i wahanol randdeiliaid Cysoni adrodd o fewn ein rheolaeth i ddiwallu gofynion lleol a gofynion Llywodraeth Cymru

Return to Home

“Supporting people with learning disabilities to lead meaningful and valued lives within their own communities”

Dychwelyd Adref

“Cefnogi pobl ag anableddau dysgu i fyw bywydau gwerthfawr ac ystyrlon o fewn eu cymunedau eu hunain”

Andrew’s story

Stori Andrew

Return to Home

• Andrew had been living at a residential

placement in Cardiff for 3 years which was jointly funded between Health and Social Care because there was nowhere in Powys that met his specific support needs

• Andrew had made a great deal of progress

since his move into the residential placement in Cardiff and had been supported in achieving a great deal of independence in terms of making choices and his wishes known

• The progression model of assessment

showed that Andrew could be really well

• Andrew’s
• Andrew’s social worker

Dychwelyd Adref

• Roedd Andrew wedi bod yn byw mewn

lleoliad preswyl yng Nghaerdydd am 3 blynedd a ariannwyd ar y cyd rhwng Iechyd a Gofal Cymdeithasol gan nad oedd unrhyw le ym Mhowys a oedd yn diwallu ei anghenion cefnogi penodol

• Roedd Andrew wedi gwneud llawer iawn o

gynnydd ers iddo symud i’r lleoliad preswyl yng Nghaerdydd ac wedi cael ei gefnogi i gyflawni llawer iawn o annibyniaeth o ran gwneud dewisiadau a chyfleu a chyfathrebu ei ddymuniadau

• Roedd y model dilyniant ar gyfer asesiad yn
• i’w
• na’r
• setlo’n

Andrew shared some information about the change in his life: “I really like my new home, I like Merlins café and the Ynyscedwyn Arms where I had my Christmas lunch. I have my own bedroom and I have a new blu-ray player in my room. I do the hoovering because I like it and it keeps my house clean. I have been to Mumbles, Neath Swansea and Brecon

• n the bus and I like

going to the pictures, bowling and for ice cream.”

Rhannodd Andrew ychydig o wybodaeth am y newid yn ei fywyd: “Rydw i wirioneddol yn hoffi fy nghartref newydd, rwy’n hoffi caffi Merlins a thafarn yr Ynyscedwyn Arms lle cefais fy nghinio

• Nadolig. Mae gen i fy

ystafell wely fy hunan ac mae gennyf chwaraewr blu-ray newydd yn fy ystafell. Rwy’n gwneud y gwaith hwfro gan fy mod yn ei hoffi a gan ei fod yn cadw’r tŷ yn lân. Rwyf wedi bod i’r Mumbles, Castell-nedd, Abertawe ac Aberhonddu ar y bws ac rwy’n hoffi mynd i’r sinema, i fowlio dêg ac i gael hufen iâ.”

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Dychwelyd Adref

Thank you

Diolch yn fawr

Delivering transformational change: ICF in West Wales

Martyn Palfreman Head of Regional Collaboration Kim Neyland Regional Programme and Business Manager West Wales Care Partnership 27 September 2017

West Wales Regional Partnership Board: Driving integration and transformation

• Established in June 2016
• 5 strategic priorities:

– Integrated commissioning – Service integration and pooled funds (initial focus

• n care homes)

– Prevention and IAA – WCCIS – Transforming LD and Mental Health Services

• First Population Assessment published March

2017

ICF in West Wales

• Key enabler of integration and transformation
• Has brought partners around a number of

tables to explore shared challenges and develop innovative solutions

• Programme has 3 components:

Transformation National priority programmes Regional priority programmes Local change through partnership

The nature and scale of the challenge (1)

The nature and scale of the challenge (2)

The risks of losing function:

• 3 days in bed = 10% loss of muscle mass
• 3 weeks in bed = 50% loss of muscle strength
• 10 days in hospital leads to 10yrs of aging in muscle

power >80 yrs old

• 48% of people >85 die within one year of being admitted

to hospital

• Approx 42% of patients >70 yrs admitted for USC have

dementia

• people with dementia stay far longer in hospital than
• ther people who go in for the same primary diagnosis.

Integrated pathway for older people: The West Wales blueprint

Integrated Whole System Pathway Components for People with Long Term Conditions and/or Frailty

Step 1 ‘Help me choose’ Public Information; Signposting; Social prescribing; Social inclusion; Supportive Communities Step 2 ‘Support me to support myself’ Enabling support; Cultural change; CRT; Opportunity to maintain strength, balance, socialisation; Telecare, Step 3 ‘Assess me and monitor me closely’ Collaborative care planning; case finding; Reablement; Housing adaptation; Respite/ short term support; commission care & 3rd Sector; Adult protection Step 4 ‘Step up my care’ Rapid response dom care; step up care; Single point access CRT; Escalation/ Contingency responses; Enhanced care home inreach; MAST +; Extra care Housing Step 5 ‘Take me to hospital’ Front door turnaround; Rapid response community services; Discharge to assess; Advocacy; Community intelligence Step 6 ‘Get me home safely’ ‘Step down’; Discharge to assess/ Recover; Intermediate Care; Housing; Community / 3rd sector broker/ Connectors; Contingency planning Step 7 ‘Continue to Care for Me’’ CHC ; Advanced care planning; Long term community care; Care home accomm; Carer assessment and support

An example in practice

Front of hospital and rapid discharge programmes:

• Transfer of Care and

Liaison Services (Carmarthenshire)

• Accessing Alternatives

to Admission (Ceredigion)

• Multi Agency Support

Team (Pembrokeshire)

Delivering the change: ICF regional forum

Priorities:

• Ensuring that ICF programmes fit with the pathway and

existing change programmes

• Developing a shared outcomes framework to measure the

difference

• Sharing local successes and challenges
• Identifying best practice and common success factors
• Understanding local differences
• Agreeing core elements of delivery
• Mainstreaming and exit strategies
• Reporting effectively to the RPB and other stakeholders

Diolch am wrando Thanks for listening

MJPalfreman@carmarthenshire.gov.uk KNeyland@carmarthenshire.gov.uk

Y Gronfa Gofal Integredig

• Digwyddiad Dysgu

Integrated Care Fund

• Learning Event

27.09.17

Welcome Croeso

Nicola Trotman

Western Bay Programme Coordinator Cydlynydd Rhaglen Bae’r Gorllewin nicola.trotman@swansea.gov.uk

Michelle King

Integrated Community Services Manager Rheolwr Gwasanaethau Cymunedol Integredig michelle.king2@wales.nhs.uk

Welcome Croeso

Emma Tweed

Chief Officer – Care and Repair Western Bay Prif Swyddog – Gofal a Thrwsio Bae’r Gorllewin emma@candrwb.co.uk

Delyth Rucarean

Community Senior Sister Uwch Brif Nyrs Cymunedol delyth.rucarean@wales.nhs.uk

Catherine Hinkin

Community Senior Sister Uwch Brif Nyrs Cymunedol catherine.hinkin@wales.nhs.uk

Key Areas of Work

Community Services (Services for Older People) Contracting and Procurement Welsh Community Care Information System Support Services for Carers Mental Health and Learning Disability Children and Young People with Complex Needs Integrated Autism Service Workforce Development Gwasanaethau Cymunedol (Gwasanaethau i Bobl Hŷn) Contractio a Chaffael System Wybodaeth Gofal Cymunedol Cymru Gwasanaethau Cefnogi i Ofalwyr Iechyd Meddwl ac Anableddau Dysgu Plant a Phobl Ifanc ag Anghenion Cymhleth Gwasanaeth Awtistiaeth Integredig Datblygu’r Gweithlu

Meysydd Gwaith Allweddol

2017-18 ICF Breakdown (revenue) 2017-18 Dadansoddiad o’r Gronfa Gofal Integredig (refeniw)

£m

Older People 5.889 Pobl Hŷn People with Learning Disabilities, Children with Complex Needs and Carers 1.494 Pobl ag Anableddau Dysgu, Plant ag Anghenion Cymhleth a Gofalwyr Integrated Autism Service 0.318 Gwasanaeth Awtistiaeth Integredig Welsh Community Care Information System 0.258 System Wybodaeth Gofal Cymunedol Cymru Third Sector 0.386 Trydydd Sector

Total / Cyfanswm 8.345 Integrated Care Fund (revenue) 2017/18 Y Gronfa Gofal Integredig (refeniw) 2017/18 Integrated Care Fund (capital 2017/18) £1.7m Y Gronfa Gofal Integredig (cyfalaf 2017/18) £1.7m

Section 33 partnership agreement for Intermediate Care Services for each locality

(approved through Cabinets/Health Board)

Third Sector arrangements:

• Small grant

scheme - £100k

• Large grant

scheme - £286k Cytundeb partneriaeth Adran 33 ar gyfer Gwasanaethau Gofal Canolraddol i bob ardal

(cymeradwywyd drwy'r Cabinetau/Bwrdd Iechyd)

Trefniadau’r Trydydd Sector:

• Cynllun grantiau bach -

£100k

• Cynllun grantiau mawr
• £286k

Community Services

Programme focusing on transforming services Agreed common service model Section 33 Outcomes Next steps

Gwasanaethau Cymunedol

Rhaglen sy’n

canolbwyntio ar drawsnewid gwasanaethau Model gwasanaeth cyffredin y cytynwyd arno Adran 33 Canlyniadau Camau nesaf

Challenges

Need for long-term strategic commitment Communication Measuring outcomes & base line data Organisational culture shift

Successes

Reductions in hospital bed usage, home care packages and care home placements Implementation of optimal model

Heriau

Angen am ymrwymiad strategol tymor hir Cyfathrebu Mesur canlyniadau a data gwaelodlin Newid i ddiwylliant sefydliadol

Llwyddiannau

Llai o ddefnydd o welyau mewn ysbytai, pecynnau gofal cartref a lleoliadau gofal cartref Rhoi’r model gorau oll ar waith

“What matters to me…” “Yr hyn sy’n bwysig i mi…”

Contracting & Procurement

Outcome Focused Assessments – Children and Adults with Complex Needs Brokerage - Mental Health and Learning Disability Optimal model – Embedding the process

Contractio a Chaffael

Asesiadau sy’n Canolbwyntio ar Ganlyniadau –Plant ac Oedolion ag Anghenion Cymhleth Broceru – Iechyd Meddwl ac Anabledd Dysgu Y model gorau oll – Gwreiddio’r broses

Challenges

Quantifying outcomes & the impact on individuals Embedding the process Provider cooperation

Successes

Embedding new ways of working Progression outcomes for individuals Savings targets realised

Heriau

Mesur canlyniadau a’r effaith ar unigolion Gwreiddio’r broses Cydweithrediad darparwyr

Llwyddiannau

Gwreiddio ffyrdd newydd o weithio Canlyniadau cynnydd unigolion Gwireddu targedau arbedion

A total of £3,120,892 has been saved. Breakdown as follows: £2,030,873 annual cashable savings achieved to date through assessment and embedding the process £810,378 annual avoidance savings through the brokerage system achieved to date £279,640 annual avoidance through negotiating uplift costs Arbedwyd cyfanswm o £3,120,892 Dyma’r dadansoddiad: Gwerth £2,030,873 o arbedion blynyddol y gellir eu trosi’n arian parod wedi’u cyflawni hyd yn hyn drwy asesu a gwreiddio’r broses Gwerth £810,378 o arbedion

• sgoi blynyddol drwy’r system

froceru a gyflawnwyd hyd yn hyn Gwerth £279,640 o osgoi blynyddol drwy gyd-drafod costau talu eraill

Teledu Bae’r Gorllewin Western Bay TV

Diolch yn fawr

2

Thank you

western.bay@swansea.gov.uk

www.westernbay.org.uk