1. Integrated Older Person's Team
Ystradgynlais

2. 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.

3. 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.

4. 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

5. 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

6. 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