1. CONWY INTERMEDIATE CARE SERVICE Intermediate Care Service manager
Conwy & Denbighshire NHS Trust
CONWY INTERMEDIATE CARE SERVICE
Glynis Tabberer
Intermediate Care Service manager

2. BACKGROUND
The Maintaining Independence Project Board a multi-agency group set up in Conwy in February 2005 including:
local authority
health
voluntary organisation
service user representatives

3. FUNDING FOR THE PROJECT
Wanless
Ref: “The Review of Health and Social Care in Wales”
Review existing provision
Develop the availability of I.C. in Conwy

4. WORKSHOP In April 2005 “The Maintaining Independence Project Board”
to involve vital stakeholders in the development which was focused on:
need
pan Conwy
sustainable
achieves the intended outcomes
reducing acute demand
maintaining people in their own homes.

5. RECOMMENDATIONS Group Staffing Multi-disciplinary Team consisting of:
Nurse Assessors
Social Workers
Occupational Therapy
Physiotherapy
TI3 Rehabilitation Assistants
Support Workers
Medical and Pharmacy support

6. RECOMMENDATIONS Service Hours
the service becomes a 7 day a week service
Monday-Friday with full cover
weekends with skeleton staff coverage to allow for emergency situations e.g. use of step-up beds, planned discharge for weekends etc

7. Service Characteristics
RECOMMENDATIONS
Service Characteristics
Two separate rapid response teams
Geographical gap
It was recommended that the intermediate care service would be:
Pan Conwy
One team managed by one division within the Conwy & Denbighshire Trust
Combined services ensuring that their current best practice was not lost
Service would also include access to step up and step down beds

8. RECOMMENDATIONS Eligibility Criteria
The service was targeted at the elderly, over 65 years of age, and registered with a Conwy GP
Aged over 18 years old
A resident of Conwy
Not requiring acute inpatient episode

9. RECOMMENDATIONS Access to service
Referrals made by an appropriate professional - health or social care
Development of additional community based services across the whole county
Improving patient flow through the health and social care system
The development of staff to meet the challenges of Intermediate Care
The introduction of a single point of referral

10. CONWY INTERMEDIATE CARE SERVICE (C.I.C.S.)
April 1st 2006
The amalgamation / re-configuration of:
the Conwy Rapid Response Rehabilitation Team, Colwyn Bay
Elderly Care Assessment Team, Abergele

11. Geographical Gaps Original areas covered Population 18,753 aged 65+
Potential increase in population of 72,247

12. Increased Staffing Resources
Intermediate Care Services Manager
TI3 Rehab Assistant
Physiotherapist
Occupational Therapist
Home Care Co-Ordinator
Social Worker
Support Workers
CPN

13. WORKING SEAMLESSLY ACROSS ORGANISATIONS
The CICS team promote working in partnership with:
The Voluntary Sector
Social Services Department
Local Health Board
Primary and Secondary Care

14. WORKING SEAMLESSLY ACROSS ORGANISATIONS
The Health Precinct
partnership project currently underway
create seamless joint working between
Conwy & Denbighshire NHS Trust
Conwy County Borough Council
Social Services

15. HEALTH PRECINCT an accessible place
rehabilitation and the return to fitness is integrated
activity related to the promotion of good health
partnership working
leisure and health staff can collaborate
develop innovative and effective physical activity interventions for the management of chronic disease conditions

16. The new facility will provide the following:
HEALTH PRECINCT
The new facility will provide the following:
Swimfit
yoga, pilates, aquarobics and circuits
Badminton, squash, athletics etc
Golf
Walking in the Park
Consulting rooms
Car parking
Public transport links
100 pieces of state of the art 'Technogym' cardio and resistance equipment
Swimming pool
Enlarged changing room facilities for sport and activities
Tennis centre
Bowling greens
Indoor bowling

17. G.P. REFERRAL SCHEME to provide supervised safe physical activities
a number of group based activity options made available during the 16 week programme
monitored though progress reviews which are used to motivate and encourage
concept will build upon current services
The Welsh Assembly is offering support through funding
scheme will be evaluated by Cardiff University

18. The methodology has been validated by:
SERVICE EVALUATION
Key Performance Indicators
KPI's were developed in 2006 using the balanced score card method
the ICD 10 coding system to calculate an average length of stay
1st Jan - 11th Feb '08 of 389 bed days saved
The methodology has been validated by:
the head of Information, Planning and Performance Management
consultation with the Clinical Coding Manager
the Information department.

19. FACILITATE EARLY DISCHARGE
the ICD 10 coding system
compared against the actual number of days that homeward bound patients remain in hospital
the patient's admission date and average length of stay for each individual's condition
Predictive date of discharge (PDD)

20. Mapping Conwy Intermediate Care Services

21. LESSONS LEARNED The importance of good change management skills
Clear access criteria
Clearly defined Performance Indicators
A robust evaluation tool which identifies subjective outcomes
Introducing the single point of referral
Identification and development of existing services linking to I.C.

22. And finally
Any Questions?