Integrated Older Person's Team Ystradgynlais

Let’s recap: Why we are changing? System Complexity Difficulties and frustrations in navigating the health and social care system. Problems include separate assessments, having to repeat their story to many people, delays in care due to the poor transmission of information Lengths of Stay Health and Social Care services are not always as responsive / flexible as needed for timely discharge from hospitals Confusing & Fragmented Services For the public, and staff, the approach can be fragmented, confusing and often with a lack of a coordinated approach to assessment, care planning and review, resulting in avoidable duplication.

What do we want to achieve? Person Centred Care promoting independence, providing maximum choice and options. All disciplines working with, and meeting the needs of, the individual Timely Access to Care tell us once, reduced waiting times Seamless Delivery of Care an identified care co-ordinator, integrated initial assessment, integrated care and support plan Integrated Systems and Pathways of Care excellent communication facilitated by being in a single team, with no inter-referring Engaged Employees supported to continuously improve the information, support, care and treatment they provide Efficient use of Resources a Powys Pound rather than a PCC or PTHB pound.

What are we doing to get to our goal? Engage with front line staff to design the system (bottom up) Co-location - achieved on 13th Jan 2016 Joint referral pathways – achieved and refined Integrated assessment – achieved and refined Ensure appropriate governance arrangements are in place (top down) Section 33 Information Sharing Protocol Team structure Engage with the Public Evaluate approach and results

We have had a few challenges on the way Co location – lack of office space and need to do complete some building alterations – staff have been very good and have worked with us. Challenging the way we work – staff have been open to speak about where they see the benefits are and the challenges for them at the frontline as we move forward with the changes Information Governance ICT – challenges still remain: Not able to access a single E document (look forward to WCCIS) Integrated Team unable to use the same printers Staff having to learn new systems

Where are we now? We went live on the 20th September 2016 – what does that mean? Duty Officer Role and supporting that role Team Structure Communication remains the key – regular meetings Evaluate and refine processes as we move forward Look forward to working with Vanguard on the 17th-20th October