1. 25 th November 2009 Local Service Board Health and Social Care Innovation Network

2. Neath Port Talbot LSB Identified the Delivering Integrated Services Project as an LSB project. Identified the Delivering Integrated Services Project as an LSB project. Key elements of the Project for NPT: Key elements of the Project for NPT: –Development of a Community Integrated Intermediate Care Service. ( CIIS) –Pilot of Lifestyle Coaches, Directory of Services and University Evaluation

3. Principles of Intermediate Care Targeted to avoid unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long term residential care, or continuing NHS in-patient care; Provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery; Has a planned outcome of maximising independence and typically enabling patient/users to resume living at home; Can be time-limited, based on an identified and assessed need Involves cross-professional working, with a unified assessment framework, single professional records and shared protocols.

4. Hospital ReferralCommunity Referral Reablement Service Adult Disability Team ERSCOPD Assessment & Intervention by individual teams Pathway Pre- CIIS Onward referral or discharge. Inc Referral between teams Referral to individual teams e.g. Enabling home care Rehab teams Rehab beds Stroke Heart failure

5. Hospital Referral / Ambulance Community Referral (HV, DN, GP, Com pharmacy, AHP, SW PRISM Flexible Support Workers Community Integrated Intermediate Care Service Community Integrated Intermediate Care Service (CIIS) Disease specific with agreed ICPs Generalist' IC services. Single Referral Point Respite Integrated Day Services COPD ERS Rehab Rapid Response Reablement Stroke Diabetes Heart Failure

6. Improvements & Benefits Patient centred not service led Patient centred not service led Reduced number of interfaces Reduced number of interfaces Eliminates duplication of effort Eliminates duplication of effort Improved transfer of information Improved transfer of information Improved coordination between teams Improved coordination between teams Increased capacity Increased capacity Reduced service shortfalls as flexible response offered Reduced service shortfalls as flexible response offered Increased skill mix Increased skill mix Economies of scale Economies of scale Flexible workers to improve coordination Flexible workers to improve coordination Team Focused Team Focused

7. Potential: Whole systems approach to the provision of community services – linking early intervention services, day services, rehabilitation services and chronic disease management Whole systems approach to the provision of community services – linking early intervention services, day services, rehabilitation services and chronic disease management Opportunity to improve joined up working with person and family/carer centred approach to assessment and integrated health & social care interventions Opportunity to improve joined up working with person and family/carer centred approach to assessment and integrated health & social care interventions Links to telecare assessment, falls service, enabling home care, day services, voluntary services, mental health services. Links to telecare assessment, falls service, enabling home care, day services, voluntary services, mental health services. Maximise opportunities and help people achieve the highest level of independence Maximise opportunities and help people achieve the highest level of independence Seamless transition of care Seamless transition of care

8. Reablement Telecare/TelehealthHEAT (SSs Assessment Team) ERS Community support workers Rehabilitation Officers Enhanced Sensory Impairment Services Social Work Physiotherapy Occupational therapy Speech and language therapy Specialist Community Nursing Integrated CIIS Support Workers CIIS Operational Manager Intermediate Care Single Point of Referral Integrated Management And Administration Development of CIIS – An Example

9. OVERALL MESSAGES Sustainability of existing investment – reliance on short term, grant funding Sustainability of existing investment – reliance on short term, grant funding Needs greater awareness of services available to all professionals and robust governance arrangements Needs greater awareness of services available to all professionals and robust governance arrangements Specialist community teams need to be realigned to bring full benefits Specialist community teams need to be realigned to bring full benefits Single point of access and communication hub essential to realise full benefit of model Single point of access and communication hub essential to realise full benefit of model Requires alignment with unscheduled care – eg GP OOH, MIU, A&E to divert patient Requires alignment with unscheduled care – eg GP OOH, MIU, A&E to divert patient Need timely access to community equipment to enable patients to be maintained at home Need timely access to community equipment to enable patients to be maintained at home

10. Benefits through being an LSB project Support from WAG when allocation of funding was in doubt. Support from WAG when allocation of funding was in doubt. Higher profile to the initiative in NPT than in neighbouring areas with cross agency understanding and support. Higher profile to the initiative in NPT than in neighbouring areas with cross agency understanding and support. Support from the LSB for this scheme being prioritised for grant applications Support from the LSB for this scheme being prioritised for grant applications

11. Delivering Integrated Services Project – Self Care, Prevention and Promotion: An Evaluation of the Lifestyle Coach Pilot “Over half of what affects people’s health is their choice of lifestyle” (Arlosk 2007)

12. ‘improve health and wellbeing of people with chronic conditions by supporting them to make the best use of their own and the communities resources by developing a model based on the co-production of health, which requires peoples to take responsibility for optimising their own health and supporting them to develop the skills and access the resources to do this successfully’ Project aims:

13. Individuals had to be over the age of 50, diagnosed with arthritis or a significant musculo-skeletal problem, and considered to have the potential to benefit from the intervention. CRITERIA

14. Skills of Lifestyle Coaches  Motivational Skills  Motivational Skills  Communication Skills  Communication Skills  Behavioural Change Skills  Behavioural Change Skills  Engagement Skills  Engagement Skills  Signposting Skills  Signposting Skills  Evaluation Skills  Evaluation Skills  Data Collection and Analysis Skills  Data Collection and Analysis Skills

15. Age Profile of Clients

16. Outcomes Dimension (EQ-5d) fewer problems more problems Dimension (EQ-5d) fewer problems more problems Mobility 8 6 Mobility 8 6 Self Care 15 3 Self Care 15 3 Usual Activities 28 3 Usual Activities 28 3 Pain/Discomfort 27 8 Pain/Discomfort 27 8 Anxiety/Depression 38 5 Anxiety/Depression 38 5

17. COMMENTS RECEIVED: “the opportunity to talk freely with a professional who had the background and knowledge to give advice and recommendations” “having time to discuss various health issues – this cannot be achieved with a five minute doctors appointment” “it has helped me think much more about my future health and that actions today will seriously impact on it” “her personality is vibrant and positive…her information is straight forward and easy to understand. You leave feeling positive” “talking and learning about my condition” “talking to someone with knowledge of facilities and opportunities in the area to increase fitness” “it has enabled me to talk…about all my feelings and anxieties far more than I could to my friends and family” “it focused my mind on actually making an effort to do what I had been thinking about for some time”

18. POSITIVE OUTCOMES: “I was very low when I first saw the coach…within 8 weeks my full confidence has returned” “an excellent experience…my wish is that she would stay at our surgery” “feel ‘normal’ after consultations” “I think this is an excellent service in that it could save the health service a great deal of future problems and expenditure by its proactive approach” “this is a truly excellent service. The very best” “I think this is a vital service for patients with disabilities, who have difficulties leaving the house because of lack of knowledge of the facilities in the area” “having it at my local doctors was very convenient” “a great opportunity for anybody with a need to discuss problems which GPs don’t have time for”

19. Benefits of being an LSB pilot Support from WAG representative on LSB to expedite a response from MtC fund. Support from WAG representative on LSB to expedite a response from MtC fund. Positive involvement in key groups within NPT e.g., Health, Social Care and Wellbeing. Positive involvement in key groups within NPT e.g., Health, Social Care and Wellbeing. High profile support across agencies High profile support across agencies