1. Gwent Frailty Programme ‘Happily Independent’ A Brief Overview of the Vision

2. 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.

3. 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

4. What do we mean by ‘frailty’? Dependency Chronic limitations on activities for daily living With one or more functional, cognitive or social impairments Vulnerability ‘Running on empty’ An overall loss of physiological reserves Loss of functional stability Co-morbidity E.g. Older people with chronic condition (Health and social care needs)

5. What we stand for: Principles & Values The underpinning principle of the Gwent Frailty Programme is to provide: ‘ Help when you need it to keep you independent’ The mantra for those delivering services is to provide help that is Sustaining independence.

6. Outcomes: What frail people tell 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.

7. 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 Community Resource Teams providing support to move individual back to independence

8. Frailty Programme layers of Activity Community Resource Teams in each Borough to bounce people away from crisis and the dependency spiral, back to a place where they can be supported to be ‘happily independent’. Seven Implementation Workstreams to support effective implementation of the above Training, Development and Cultural Change Management Programmes with the staff both in the Intermediate Care Teams and in the wider health and social care community to promote the ethos of sustaining independence Work with Local Service Boards to ensure that other supporting factors for sustaining independence are provided e.g. access to adequate housing, benefits, community safety etc. Influencing and aligning with developments in the wider Community Based Services, to ensure that the Frailty Programme is a catalyst for change and not simply and ‘bolt on’ set of services.

9. The Locality Model: A tailored approach 5 boroughs need to tailor service provision to meet the needs of their diverse and distinctive communities. Locality approach to cover: Crisis Intervention Reablement Longer Term Care (including Continuing NHS Healthcare)

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

11. Frailty Programme Priorities 2009/11 Implement Service Models For: Urgent Assessment and Intervention; Independent Living & Reablement; Including interface with CHC, CCM and core services;

12. How they’ll fit together : Flexible health and social care ‘Care & Wellbeing’ workers. Potential to work across teams & move through the system with the individual to provide continuity CCM CHC 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 Integrated Community Resource Team Manger

13. Common Service Characteristics: Access Hours of operation Response time Comprehensive needs assessment Service provision Access to other specialities

14. Urgent Assessment & Intervention “a service providing an emergency response at home, or in an emergency assessment unit setting, for people identified as frail, who are experiencing a crisis in their health, functional ability, social or environmental well- being.”

15. Independent Living & Reablement For the purpose of the Programme ‘rehabilitation’ is viewed as a specific process, sometimes specialist, which can be part of an approach that is geared towards ‘reablement’, with reablement conveying more of the outcomes to be achieved which will / can involve a number of different processes including: Confidence building. Consideration of other independence factors such as housing, emotional well being. In other words, Reablement corresponds more to an outcome than a process.

16. Independent Living & Reablement Up to 6 weeks coordinated reviewing and ongoing reablement elements to sustain independence – i.e. based on need can be a few days or could be longer than 6 weeks Rapid access to equipment and minor adaptations The ability of Care & Wellbeing Workers to interchange between rapid access and longer term approaches

17. Independent Living & Reablement Includes people NOT living in their own homes, e.g. residential / nursing home care, respite services. Eligibility common across Local Authority and Health. Team and locality approach linking with other inputs, i.e. crisis response and longer term support but also with GP’s and practice staff in location.

18. What the Integrated Community Resource Team will look like: It is proposed that each locality team will include the following members: Administrative support A team of Care & Wellbeing Workers Registered General Nurses Registered Mental Nurses Social Workers Pharmacist Specialty Doctors Occupational Therapists Physiotherapists Reablement Nurses Social Workers Reablement Assistants Senior Reablement Assistants Consultant Physician

19. Next Steps Service Model Capacity Plan Workforce Plan Service Model Capacity Plan Workforce Plan Financial Plan

20. Implementation Workstreams 1.Communication & Stakeholder Engagement Development of a communication strategy for all key stakeholders Continued user engagement and feedback Staff road shows and engagement with the change process

21. Implementation Workstreams 2. Workforce Planning Refinement of workforce requirements to deliver the Programme Identification of core competencies Development of training programme to meet skills gaps/new ways of working and thinking

22. Implementation Workstreams 3. Governance & Structure Management of risks NB handovers and transfers of care Addressing different interpretations of risk Agreed standards and protocols Clear lines of management & accountability Compliance with CSSIW regulatory requirements Compliance with health Clinical Governance requirements

23. Implementation Workstreams 4. Outcome Indicators, Performance and Continuous Improvement Development of outcome indicators to ensure programme delivers what users want and associated monitoring arrangements. Development of business performance indicators and associated monitoring arrangements Feedback loop to ensure learning & service improvement

24. Implementation Workstreams 5. Information sharing & Single Point of Access Develop agreed information sharing protocols Develop safe means of electronic transfer Develop the model for the Single Point of Access

25. Implementation Workstreams 6. Locality Planning (including longer-term care and interfaces with other services) Using the outputs from the workstreams above to support planning for preventative services and delivery at locality level Ensuring that core standards are met and outcomes achieved whilst retaining ‘local colour’ Identify local components of the Longer term Approach

26. Implementation Workstreams 7. Financial Modelling/ Building the Business Case Using the engagement from the workstreams above to: confirm demand map capacity identify the resource gaps calculate the financial requirements Pooled budget arrangements

27. Key Milestones Strategic Outline Case submitted October 2009 Groundwork from workstreams completed by end of March 2010 Localities sign up and begin implementation from April 2010

28. Contact details Lynda Chandler: Programme Manager Lynda.chandler@torfaen.gov.uk Tel: 01495 742411 Mobile: 07939618877 Website: http://www.gwentfrailty.torfaen.gov.uk http://www.gwentfrailty.torfaen.gov.uk