1. Update: Cardiff Partnership Board December 2012
Item 2.1
Update:
Cardiff Partnership Board
December 2012

2. ‘what does this mean for Wyn?’
What’s the issue?
Older People’s Workstream, Integrating Health & Social Care Programme and Cardiff Partnership Board.
Formally established September 2011
Why ‘Wyn Campaign’?
- snappier title & better branding potential
- Campaign approach needs passion & commitment
- makes it easier to talk in person-centred terms i.e.
‘what does this mean for Wyn?’

3. What did we do? Agreed vision;
Agreed model (designed in collaboration);
Agreed aspirational pathway for Wyn in the community;
Roadmap to Integration/Workforce Development Plan;
Wyn Phase 1c implemented from 1st November 2012 (using Invest to Save loan).

4. The Model: ‘Team Around Wyn’
Targeted Interventions
Medicines Management
Facilitated Early Discharge Case Management
Falls Prevention/Management Support Carers
Recovery & Reablement Support to Care Homes
Step up/admission avoidance Targeted monitoring
Longer-term Care
Universal Services
Primary Care
Risk Stratification
Healthy Ageing
Signposting
Comms Hub
Joint Commissioning Framework/Unit
Focused improvement in Advance Care Planning and End of Life Care
Co-ordination
Team Around Wyn

5. Step Change only: Targeted Interventions
Wyn Phase 1c Components
Step Change only: Targeted Interventions
Community Resource Teams working to a single operational policy (improved consistency across the localities)
Integrated Discharge Team
Frail Older People’s Advice & Liaison (FOPAL)
Elderly Care Assessment Unit (ECAS)

6. Focussed Activity Timely facilitated discharge from hospital
‘Step-up’ interventions for
- reducing harm from falls
- improving chronic conditions management
- care home in-reach
- multidisciplinary support to Wyn as identified by FOPAL and ECAS.
Delivered mostly, but not exclusively, to older people.

7. Working together differently for Wyn
Workforce development; bringing frontline staff together from health, social care & voluntary sector
Information Sharing & IT solutions
Co-location
Stakeholder engagement; strong messages and challenges coming from our citizens.

8. What barriers did we face?
Financial climate & risks if pump-prime funding is not an option
Ability to respond in a ‘agile’ manner (reporting, governance structures, matching capacity to demand, pressure to be seen to perform)
Maintaining momentum and morale

9. What are we doing next? Embed and learn from Phase 1
Implement as much of Phase 2 as possible by using existing resource differently
Actively continue work on culture and workforce development
Maintain communication/feedback with stakeholders
Continue strategic debate re structural integration.

10. What do we need from CPB?
Support to continue taking forward the work of the Older People Programme through the Integrated Health and Social Care Programme Board.