1. ‘Happily Independent’ ‘Happily Independent’ Gwent Frailty Programme: Update presentation August 2011

2. The Vision: ‘Supporting frail people in Gwent to be happily independent’

3.  People are individuals with a life, a history and a future;  They are the experts in their own life and we need to tap into that expertise;  The present system is untenable & does not treat people as well as we want it to;  We work best when we work together, with shared values and joint outcomes that keep the person at the centre. The Ethos:

4. Why Do it?  It’s what older people tell us they want!  Integrated model of health and social care delivery  Represents a significant shift in the way public services are provided for frail people (to a community focus)  Our current way of working is unsustainable and doesn’t deliver the goods.

5. Outcomes: what older people in Gwent told us they want.  Be able to remain living in their own home with support  Receive services in their home  Be listened to by people who are responsible for providing services to assist them  Have their health and social care problems solved quickly and considered as a whole rather than individually.

6. What the CRTs will look like… Flexible health and social care ‘Support & Wellbeing’ workers. Potential to work across teams & move through the system with the individual to provide continuity Chronic Conditions Management Continuing Health Care Palliative care Long term care Community Resource Team providing:   Urgent Comprehensive Needs Assessment   Rapid Response to health & social care need   Emergency Care at Home   Reablement   Falls Integrated Community Resource Team Manger

7. Team Composition: Team Composition: It is proposed that each locality team will include the following members:  Administrative support  A team of Support & Wellbeing Workers  Registered General Nurses  Mental Health Practitioners  Social Workers  Pharmacist  Specialty Doctors  Occupational Therapists  Physiotherapists  Dietetics/SALT/podiatry (in future?)  Consultant Physician/appropriate medical input

8. Core standards  Single Point of Access  7 days a week 365 days a year  8am to 8pm as a minimum  2-4 hours response time (for both health and social care urgent components)  Comprehensive Needs Assessment  Management/ Hospital @ Home for up to 14 days in response to assessed need  Hot Clinics for rapid access to specialist and diagnostic  Rapid access to equipment and minor adaptations.  Up to 6 weeks reablement & review  Onward referral where required

9. The Workstreams: 13 in total during development phase; now rationalised to 4 ongoing for implementation:  Communication & Stakeholder Engagement  Workforce Planning  Information Sharing & Single Point of Access  Financial Modelling

10. Locality Implementation Groups  Franchise Model - each Borough to assess local need and design their specific CRT in response, e.g.  Size/number  Location  Links to other local drivers e.g. Setting the Direction; Health, Social Care & Wellbeing Strategy etc

11. Invest to Save monies………  £9m over 2010/11 – 2012/13  Approximately £3m, £2.3m, £3.7m  Non – recurring funding = transfer of resource  Payback of loan 5 – 7 years

12. What was different from 4 th April 2011?  Implementation began  CRTs in each locality co-located & operating under one integrated manager  Started different ways of working together  Single Point of Access operational  Some local variation to begin with.

13. Early Challenges  Some pockets of resistance to new referral system  IT glitches/slippage in implementing new technologies  Variations in medical model still being agreed in Blaenau Gwent and Monmouthshire  Consistent pan Gwent Falls Service: proving more complex than first anticipated, but in progress  Collation of performance data

14. Current Referral Rates (per month)

15. Referral Sources

16. Calls per day

17. Target areas to address over next few months  ‘Front end’ of hospital - MAU/A&E  Alternate Falls Pathway with Ambulance service  Weekend referrals  Continue planned recruitment to boost CRT capacity

18. Some early achievements  Single Point of Access operational  Functionality to safely send electronic information to support referral  Primary Care colleagues using service well  CRT Portal continues to develop.  All first responders supplied with Blackberry devices and trained  Digipen technology to be rolled out end September  Positive responses from staff to new ways of working  Anecdotal feedback indicates CRT intervention is welcomed by service users.

19. Some early feedback “May I pass my thanks to the staff who attended me at my home during the last week. Their level of care was exemplary. Having contracted cellulitis for the third time I was not looking forward to spending another week in hospital on a drip again. To be treated at home by your response team was a revelation, good for me and good for the NHS as it saved a bed and probably the first of many for my doctor.”

20. Some early feedback “ I would like to give a big thank you to the CRT for the support that was provided when I was discharged from the Nursing Home. The input and support from your team allowed me to return home. The determination, time and dedication spent on my self ensured that my discharge home was safe and successful.”

21. Contacts: Programme Manager: Gill Lewis – Gill.lewis3@wales.nhs.uk Tel: 01633 623828 Website: http//:www.gwentfrailty.org.uk