1. Wrexham South Locality Health & Well-Being Pilot Results and Findings to date Wrexham South Locality Health & Well-Being Pilot Appendix 4

2. Wrexham South Locality Health & Well-Being Pilot Changes to Workload Management In order for the Pilot to be more responsive it was necessary to change previous working practices: Multiple points of referral: Contact and Assessment Team; Unique Care Meetings; MDT’s held at GP practices; Weekly Meetings with District Nursing Practitioners Traditionally, referrals were reviewed and prioritised on a weekly basis. This is now done on a daily basis. Within the hospital setting, referrals to Social Services are discussed with Patients at the point of admission rather than when they are ready for discharge. Ward staff inform the social worker if there are any significant changes in a person’s needs on an almost daily basis. Previous practice would have meant weekly updates rather than daily ones.

3. Wrexham South Locality Health & Well-Being Pilot The Results: Responses times have been reduced: Had a referral been submitted to the Contact and Assessment Team, then on average, it can take up to 48 hours before the referral progresses to the appropriate team. If the referral progressed to the Adult Community Team, then it would have been allocated and contact made on the same day. Other teams have waiting lists and referrals are prioritised and placed on the waiting list to be allocated at weekly allocation meetings. “92% of the individuals seen by the pilot were seen before the referral passed through the traditional allocation process.” “71% of the individuals seen by the pilot had partially completed assessments before the referral had passed through the traditional allocation process.”

4. Wrexham South Locality Health & Well-Being Pilot More timely and robust discharges. Working more closely with ward staff and other professionals has enabled more holistic and multi- disciplinary assessments. Using the Generic Health Care Support Worker to support patients from hospital to home has facilitated more timely discharges. Where care has been transferred to independent domiciliary care providers, the use of the Generic Health Care Support Worker has ensured a greater continuity of care. Qualitative questionnaires indicate that patients being supported by the GHCSW feel as though they are “not forgotten about” once they have been discharged from the hospital. A large proportion of patients stated that they felt the care given by the Generic Health Care Support Worker was “far superior than that of domiciliary care staff”. Unique Care and GP MDT meetings have ensured a more holistic review of the patients’ needs and abilities following discharge from hospital. Multi-disciplinary reviews have enabled further risks to be identified and minimised very promptly.

5. Wrexham South Locality Health & Well-Being Pilot

8. Prevention of Hospital Admissions. The introduction of the Generic Health Care Support Worker has also enabled the prevention of admissions: 41% of the individuals who were seen by the Pilot were supported in their own home and whilst all of these may not have necessarily needed a hospital admission, the opinion of these individuals was that they preferred to be supported in their own home rather than access hospital or temporary residential care. By using the Generic Health Support Worker in these situations it was possible to monitor situations more closely and on four occasions the Generic Health Care Support Worker was instrumental in facilitating prompt hospital admissions with the support of the G.P.

9. Wrexham South Locality Health & Well-Being Pilot

11. Information sharing. Exploring the potential of Unified Assessment to reduced duplication and paperwork. Sharing of local information and third sector knowledge.

12. Wrexham South Locality Health & Well-Being Pilot What has been accomplished so far: Identifying more individuals with a chronic condition; Needs are being assessed & met from both health and social care perspectives; Increased utilisation of third sector services; Reduced length of stays in Chirk Hospital with an increased number of admissions; Responded quicker to Social Services referrals with an increased number of referrals; Identified that people prefer to be supported/cared for in their own home rather than hospital or care settings; Identified that people prefer to spend their last days at home with support.