1. ‘Happily Independent’ ‘Happily Independent’ Gwent Frailty Programme Introductory Presentation

2. The Vision: ‘Help when you need it to keep you independent’

3. The Ethos: People are individuals with a life, a history and a future; They are the experts in their own life and we need to tap into that expertise; The present system is untenable & does not treat people as well as we want it to; We work best when we work together, with shared values and joint outcomes that keep the person at the centre.

4. Why Frailty? Social, environmental, physical and mental health needs closely entwined: it just makes sense! Cuts across traditional boundaries between primary and secondary health care and between health and social care. The evidence says it works

5. Frailty Definition Dependency Chronic limitations on activities for daily living With one or more physical, or social needs, including those who have dementia Vulnerability ‘Running on empty’ Usual coping mechanisms aren’t working Co-Morbidity E.g. People with a chronic condition who as a result may have health, social care and/or housing needs.

6. Why Do it? It’s what older people tell us they want! Integrated model of health and social care delivery Represents a significant shift in the way public services are provided for frail people (to a community focus) Our current way of working is unsustainable and doesn’t deliver the goods.

7. Outcomes: what older people in Gwent told us they want. Be able to remain living in their own home with support Receive services in their home Be listened to by people who are responsible for providing services to assist them Have their health and social care problems solved quickly and considered as a whole rather than individually.

8. And a bit of this…… Be safe and secureBe safe and secure Live in good quality homesLive in good quality homes Be able to cook, wash, clean and go outBe able to cook, wash, clean and go out Be able to maintain their standardsBe able to maintain their standards Be financially stable to make independent choicesBe financially stable to make independent choices Be receiving the benefits available to enable them to live independentlyBe receiving the benefits available to enable them to live independently Not be lonelyNot be lonely Have a supportive familyHave a supportive family Have good friends and neighbours keeping an eye out for themHave good friends and neighbours keeping an eye out for them Have companyHave company Be going out to social activitiesBe going out to social activities Have planned for old ageHave planned for old age Be accessing peer supportBe accessing peer support Be able to keep a pet if they so wishBe able to keep a pet if they so wish

9. Integrated Locality Approach Acute Intensive packages Episodic or longer Term interventions Identified needs warranting integrated approach Some identified health/social care needs Preventative Services Community Context

10. Frailty Programme Layers: Community Resource Teams Training, development, cultural change Work with LSBs etc Influencing & aligning

11. What the CRTs will look like… Flexible health and social care ‘Support & Wellbeing’ workers. Potential to work across teams & move through the system with the individual to provide continuity Chronic Conditions Management Continuing Health Care Palliative care Long term care Community Resource Team providing:   Urgent Comprehensive Needs Assessment   Rapid Response to health & social care need   Emergency Care at Home   Reablement   Falls Integrated Community Resource Team Manger

12. Wallace.,C, (2009) An exploratory case study of health and social care service integration in a deprived South Wales area. Collaborative service user/carer relationship Independence Dependence Integrated CRTs providing support to move individual back to independence

13. Team Composition: Team Composition: It is proposed that each locality team will include the following members: Administrative support A team of Support & Wellbeing Workers Registered General Nurses Registered Mental Nurses Social Workers Pharmacist Specialty Doctors Occupational Therapists Physiotherapists Dietetics/SALT/podiatry Consultant Physician

14. Core standards Single Point of Access 7 days a week 365 days a year 8am to 10pm 2-4 hours response time (for both health and social care urgent components) Comprehensive Needs Assessment Management/ Hospital @ Home for up to 14 days in response to assessed need Hot Clinics for rapid access to specialist and diagnostic Rapid access to equipment and minor adaptations. Up to 6 weeks reablement & review Onward referral where required

15. Case Scenario 1 Mrs Jones, a 45 year old lady with Multiple Sclerosis, develops urinary symptoms. Her GP visits and treats Mrs Jones for a urinary tract infection. 24 hours later however she is still not coping and is ‘off her feet’. The GP refers her, via the Single Point of Access, to the Community Resource Team. They visit within the hour and assess her thoroughly. They exclude other potential diagnoses and assess that Mrs Jones needs support to help her recover. The registered nurse arranges for social care and occupational therapy to help Mrs Jones get back to independence as quickly as possible. A Support & Wellbeing Worker visits 3 times a day to help Mrs Jones with her daily living needs. After a week, the infection is resolved, but Mrs Jones is still unsteady and lacking in confidence. Further reablement support is developed by the therapists in the team and delivered by the Support & Wellbeing Worker. A discharge letter summarising Mrs Jones’ outcomes and onward referral is sent to her GP.

16. Case Scenario 2 Mrs Jones is 70 years old and is bed ridden. She is cared for by her husband who is normally a physically fit 75 year old. Mr Jones develops chest pain and is rushed to hospital by ambulance leaving Mrs Jones alone. Mrs Jones is referred to the Community Resource Team for support during her social care crisis.

17. Story so far……… Established what older people want ‘Towards Independence for Older people in Gwent’ Articulated the vision ‘Happily Independent’ Achieved executive and political sign up to the Strategic Outline Case Seven implementation workstreams up and running Locality Implementation Groups set up (Franchise Model)

18. The Workstreams: Communication & Stakeholder Engagement Workforce Planning Governance & Structures Performance Management & Evaluation Information Sharing & Single Point of Access Financial Modelling Locality Planning

19. Locality Frailty Implementation Groups Each Borough to assess local need and design their specific CRT in response, e.g. Size/number Location Date to ‘go live’

20. Coming soon……. Response to bid heard for ‘pump prime’ funding expected late Spring 2010 Final, detailed plans to be presented to Boards, Cabinets etc September 2010 Community Resource Teams up and running in all localities by end of March 2011

21. Pieces of work we need to do………….. Carers Strategy Mental Health Knowledge Management Referral management (criteria, screening, Frailty Index etc); Out of hours/ On Call arrangements, including cross-boundary cover at times of peak demand. Falls Strategy Telecare

22. Contacts: Programme Manager: Lynda Chandler – Lynda.chandler@torfaen.gov.uk Tel: 01495 742411 Website: http//:www.gwentfrailty.torfaen.gov.uk