1. Programme for Health Services Improvement in Cardiff and the Vale of Glamorgan REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE CARDIFF AND VALE NHS TRUST YMDDIRIEDOLAETH GIG CAERDYDD A’R FRO

2. REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE IN CARDIFF AND THE VALE OF GLAMORGAN Independent Sector Community Based Services Patient Acute Services GP Social Care Health and Social Care Contact and Assessment Centre Community Based Rehabilitation and Intermediate Care Services Community NursingCommunity Social Work Core Home Care Services Enablement Service Day Centre Acute Medical Beds Independent Sector beds Acute Hospital Rehabilitation Community Hospital Rehabilitation and Care Outpatients Unscheduled Care EU/MEAU/MAU Joint health and social care services Social Care Services Trust Services Independent Sector

3. HEALTH AND SOCIAL CARE CONTACT AND ASSESSMENT CENTRE single point of referral and access single telephone number for Cardiff and one for the Vale of Glamorgan integrated health and social care teams locality based – on resource centre populations - ? 2 for Cardiff and 1 for the Vale all referrers must have confidence that they are able, where appropriate and necessary, to talk to people at a senior level and have confidence in the assessment service staffed by: - senior nurse - ?coordinator - 2 call takers - manager initial unified assessment – based on good screening, presenting issues referral on to : - specialist assessment - case managers - joint equipment store - community based rehabilitation and intermediate care team - acute day treatment - consultant geriatricians - specialist community based teams - generic community nursing/therapy services - specialist palliative care - in-patient admissions - diagnostics - supported care provision of feedback to referrers appropriate signposting to other services where appropriate INTEGRATED COMMUNITY BASED REHABILITATION AND INTERMEDIATE CARE REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE IN CARDIFF AND THE VALE OF GLAMORGAN

4. HEALTH AND SOCIAL CARE CONTACT AND ASSESSMENT CENTRE INTEGRATED COMMUNITY BASED REHABILITATION AND INTERMEDIATE CARE sector/locality based around resource centre populations rapid multi-disciplinary assessment acute/rapid response active rehabilitation and reablement links to specialist services North Cardiff West Cardiff Central Cardiff South and East Cardiff PenarthBarry REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE IN CARDIFF AND THE VALE OF GLAMORGAN

5. INTEGRATED COMMUNITY BASED REHABILITATION AND INTERMEDIATE CARE SERVICES A multi-disciplinary team based on resource centre populations providing: - Rapid assessment service - Acute/rapid response - Community based active rehabilitation and Reablement - Maintenance and prevention services Team membership may include: - Identified lead consultant - GPwSIs - Nurse consultants/nurse specialists/rehabilitation nurses (including liaison)/”acute” nurses/ community nurses - Therapists – physiotherapists/OTs/podiatry/dietetics/SLTs - Home care/social workers - Diagnostic support staff - Intermediate care generic support staff Link to more specialist services - Acute day treatment services – 2 for Cardiff and 1 for the Vale of Glamorgan - in-reach hospital services - chronic disease management services - specialist services – eg Parkinsons/stroke/continence REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE IN CARDIFF AND THE VALE OF GLAMORGAN

6. INTEGRATED COMMUNITY BASED REHABILITATION AND INTERMEDIATE CARE – LOCALITY TEAM BASED MODEL MULTI-DISCIPLINARY TEAM: identified lead consultant physician GPwSIs Nurse consultants/nurse specialists/rehabilitation nurses (including “liaison”)/”acute” nurses/community nurses Therapists – physiotherapists/OTs/podiatry/dietetics /SLTs Home care/social workers/carer support Diagnostic support staff (linked to resource centres) Intermediate care generic support staff Voluntary sector RAPID ASSESSMENT SERVICE - geriatrician led comprehensive assessments with support from GPwSIs, nurse/therapy consultants - access to diagnostics – radiology, pharmacy, ultrasound ACTIVE REHABILITATION AND REABLEMENT - support transition from medical dependence to functional independence - provide a coordinated package or therapy, social care and nursing - provide support to carers RAPID/ACUTE RESPONSE - avoid unnecessary admissions, and links to unscheduled care services, including link to A&E to prevent admission - support discharge - in-reach services to hospital to pull people out - MAINTENANCE/PREVENTION - - provision of generic, ongoing services to people outside hospital – including step up/down facilities REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE IN CARDIFF AND THE VALE OF GLAMORGAN GENERIC PRINCIPLES FOR WORKING: -Services will be provided through the multi-disciplinary team to people in residential care and nursing homes in the same way that they would be for people living in their own homes – ie they will have access to rapid assessment, acute/rapid response, rehabilitation and reablement and maintenance/prevention services. -The multi-disciplinary team will provide pro-active assessment and preventative services to people in nursing and residential care homes, in conjunction with GPs and community pharmacy to prevent them “tipping over” into hospital based care. -MDT lead based on most appropriate professional dependent on patient’s individual assessed need. -Unified assessment will be the core of the assessment process. -Teams to provide first point of support to GPs and primary care.

7. LOCALITY TEAM BASED MODEL 1 per resource centre Joint Equipment Service 1 for Cardiff and Vale of Glamorgan Acute Day Treatment Service 2 for Cardiff 1 for the Vale Continuing health care/NHS respite services – in independent sector Voluntary sector services Social care services, including day centres In-patient care Residential and Nursing home care beds – independently and LA funded Unscheduled care and out of hours care Education, training and research centre – linked to Acute Day Treatment Service Community based specialist services eg chronic disease management REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE IN CARDIFF AND THE VALE OF GLAMORGAN

8. Community ART/ECAS/Acute response centre EU/Medical/Surgical Assessment Multipurpose Acute Admission Ward Specialist wards Acute Rehab General wards Community Home/Slow Stream Rehab/Social Services etc

9. REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE IN CARDIFF AND THE VALE OF GLAMORGAN FURTHER WORK REQUIRED: Demand and capacity modelling – balance between different levels of care In-patient model/flow Links with other workstreams Tesco Superstore vs Tesco Extra Staffing requirements Assistive technologies

10. RISKS: Unquantified future demand for services Funding Workforce Independent sector Links with local authorities Provision of “up-stream” services Substitution vs additional REHABILITATION, INTERMEDIATE CARE AND SERVICES FOR FRAIL OLDER PEOPLE IN CARDIFF AND THE VALE OF GLAMORGAN