‘Me, my home, my community’ – delivering seamless care across Cardiff and Vale of Glamorgan Regional Partnership Board Update PSB 20 November 2018
Role of the RPB Regional Partnership Board’s role is to: • - Ensure partners work effectively to improve outcomes for people in their area. - Ensure the partnership bodies provide sufficient resources for the partnership arrangements, in accordance with their powers under section 167 of the Act - Determine where integrated services, care and support will be most beneficial to people within their region, informed by the views of service users. - Ensure partners prioritise integration with respect to: � Older people with complex needs and long term conditions, including dementia; � People with learning disabilities; � Carers, including young carers; � Integrated Family Support Services; � Children with complex needs due to disability or illness. The Partnership Arrangements (Wales) Regulations 2015 require that each • regional partnership board must prepare an annual report on the extent to which it has met its objectives.
Governance Structure
Our vision for delivering seamless care is underpinned by our 4 design principles… Cardiff and Vale of Glamorgan Regional Partnership Board ‘s A Healthier Wales’ Vision Design Principles 4
Learning from Canterbury, NZ… Vision – consistent and • compelling vision Clinical engagement and • empowerment Culture – permissive and • accountable Patient/Citizen centred – • system wide “It should be seamless for the person...they have no sense of having been passed from one organisational structure to another...the services are just organised around them”.
Integrated Care Fund 2018/19 £ Frail Older People: £3.743m, LD/CwCN: £1.737m, WCCIS: £201k, Autism: £367k, Capital: £3.810m
What’s worked well? • Focused effort upon the needs of key population groups ; • Encouraged partners to work collaboratively with a focus upon best practice; • Use of Results Based Accountability as an outcome focused performance management model; • Helped people to think innovatively and test new ways of working; • Focus upon community ; • Managing demand from population growth .
‘Get Me Home’ Plan – Delayed Transfers of Care RPB Target: 25% reduction on June 2015 position (maximum of 82 patients)
Impact of the Preventative Approach
New Service Model Services promote prevention, health and wellbeing, independence • and empowerment, recognising that a wide range of social and Independence health needs may have an impact on a persons wellbeing. * e.g. Public Health / Healthy Communities , Community Networks / and Wellbeing Befriending, dementia friends, Leisure and Learning Activities, Information and Advice WELLBEING COORDINATOR Services provide a first point of contact, they screen and assess, • providing early intervention and sign posting. Where a persons needs are stable and not complex, services provide routine on-going First Point of Contact support. *e.g. Contact Centres, Equipment / Aids, Third Sector, Care & Repair, GP and Stable Non-Complex Care Dental Surgeries, Sheltered Housing, Independent Living Service, Day Opportunities • Services provide a flexible and coordinated response to a persons rising unstable need. They either provide, an intensive reablement Intensive and/or service or an ambulatory care intervention. Both prevent Enhanced inappropriate long term care and avoid hospital admissions. * e.g. Occupational Therapists, Telecare Plus, Domiciliary Care, Community Resource Teams, Step Up / Down Accommodation, Mental Health Teams , Frail Older Persons Advice and Liaison Service, Elderly Care Assessment Service Long Term, • Services provide for people whose needs are not necessarily low but are stable, additional support may be needed to meet daily living Stable needs. Rising complexity can mean care planning by specialist multi- Complex Care disciplinary teams to avoid unstable acute hospital admission. *e.g. Extra Care Accommodation, District nursing, End of Life Care, Residential Care Homes, Nursing Care Homes • Services provide for people whose needs are highly unstable and/or Specialist for highly specialist assessment and care. Integrated discharge planning supports timely discharge. * e.g. Specialist Assessment, Inpatient Services, Integrated Discharge Team * NB some services will fall under more than one tier of intervention 10
Joint Commissioning and pooled budgets Mapped core resources • Cluster analysis to inform locality working • Completion of ‘Housing with Care and Care Ready’ • research – what accommodation do we need to build by 2035 and where… It is forecasted that by 2035 Cardiff will • require an additional 1,787 older people's housing units, 609 housing with care units and 655 nursing care beds. New Health, Housing and Care • Programme Board – reports to RPB
Locality Working • Completion of ‘Perfect Locality’ specification • Development of Hubs and Well-being Centres • Mapping of social prescribing and well-being services • Sheltered blocks refurbished - modernised and accessible with services on site for wider community of older people – could be social activities / health and advice services • Development of neighbourhood/cluster care networks using local assets, staff and services • Sustainable ‘careforce’ across the statutory, third and independent sectors • Asset based community development
A Healthier Wales “Delivering a whole system approach to health and social care which is focussed on health and well-being, and on preventing illness”
Our Proposal Accelerated Cluster Development Seamless Social Prescribing Developing a Single Point of Access for GP Triage Get Me Home Preventative Services Get Me Home Plus Developing an ACE Aware Approach to Resilient Children and Young People Developing Place Based Integrated Community Teams 7m
Next Steps Delivering a Partnership Response to ‘A Healthier Wales’ – including • 2 nd Transformation Bid by Christmas Continued emphasis on prevention, neighbourhood/cluster working • and community networks Embedding social prescribing / wellbeing approaches – utilising local • assets Development of an in-hospital ‘front door’ • Continued development of multi-agency hubs and well-being centres • Continue to develop multi-disciplinary locality teams with integrated • management structures Review of Area Plan delivery in March 2019 • Relationship of RPB and PSB – Social Care Wales undertaking national • review to report back in New Year
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