Gwent Frailty Programme

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Gwent Frailty Programme

• Happily Independent
• A Brief Overview of the Vision

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Why do it?

• Its 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
  doesnt deliver the goods.

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Why Frailty?

• Social, environmental, physical and mental health
  needs closely entwined it just makes sense!
• Cuts across traditional boundaries between
  primary and secondary health care and between
  health and social care.
• The evidence says it works

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What do we mean by frailty?

• Dependency
• Chronic limitations on activities for daily
  living
• With one or more functional, cognitive or social
  impairments
• Vulnerability
• Running on empty
• An overall loss of physiological reserves
• Loss of functional stability
• Co-morbidity
• E.g. Older people with chronic condition
• (Health and social care needs)

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What we stand forPrinciples Values

• The underpinning principle of the Gwent Frailty
  Programme is to provide
• Help when you need it to keep you independent
• The mantra for those delivering services is to
  provide help that is
• Sustaining independence.

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OutcomesWhat frail people tell 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.

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Wallace.,C, (2009) An exploratory case study of
health and social care service integration in a
deprived South Wales area.
Community Resource Teams providing support to
move individual back to independence
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Frailty Programme layers of Activity
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The Locality ModelA tailored approach

• 5 boroughs need to tailor service provision to
  meet the needs of their diverse and distinctive
  communities.
• Locality approach to cover
• Crisis Intervention
• Reablement
• Longer Term Care (including Continuing NHS
  Healthcare)

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Integrated Locality Model
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Frailty Programme Priorities 2009/11

• Implement Service Models For
• Urgent Assessment and Intervention
• Independent Living Reablement
• Including interface with CHC, CCM and core
  services

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How theyll fit together
Integrated Community Resource Team Manger
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Common Service Characteristics

• Access
• Hours of operation
• Response time
• Comprehensive needs assessment
• Service provision
• Access to other specialities

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Urgent Assessment Intervention

• a service providing an emergency response at
  home, or in an emergency assessment unit setting,
  for people identified as frail, who are
  experiencing a crisis in their health, functional
  ability, social or environmental well-being.

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Independent Living Reablement

• For the purpose of the Programme rehabilitation
• is viewed as a specific process, sometimes
• specialist, which can be part of an approach that
  
• is geared towards reablement, with reablement
• conveying more of the outcomes to be achieved
• which will / can involve a number of different
• processes including
• Confidence building.
• Consideration of other independence factors such
  as housing, emotional well being.
• In other words, Reablement corresponds more to an
  outcome than a process.

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Independent Living Reablement

• Up to 6 weeks coordinated reviewing and ongoing
  reablement elements to sustain independence
  i.e. based on need can be a few days or could be
  longer than 6 weeks
• Rapid access to equipment and minor adaptations
• The ability of Care Wellbeing Workers to
  interchange between rapid access and longer term
  approaches

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Independent Living Reablement

• Includes people NOT living in their own homes,
  e.g. residential / nursing home care, respite
  services.
• Eligibility common across Local Authority and
  Health.
• Team and locality approach linking with other
  inputs, i.e. crisis response and longer term
  support but also with GPs and practice staff in
  location.

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What the Integrated Community Resource Team will
look like

• It is proposed that each locality team will
  include the following members
• Administrative support
• A team of Care Wellbeing Workers
• Registered General Nurses
• Registered Mental Nurses
• Social Workers
• Pharmacist
• Specialty Doctors

• Occupational Therapists
• Physiotherapists
• Reablement Nurses
• Social Workers
• Reablement Assistants
• Senior Reablement Assistants
• Consultant Physician

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Next Steps
Capacity Plan
Service Model
Financial Plan
Workforce Plan
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Implementation Workstreams

• 1.Communication Stakeholder
• Engagement
• Development of a communication strategy for all
  key stakeholders
• Continued user engagement and feedback
• Staff road shows and engagement with the change
  process

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Implementation Workstreams

• 2. Workforce Planning
• Refinement of workforce requirements to deliver
  the Programme
• Identification of core competencies
• Development of training programme to meet skills
  gaps/new ways of working and thinking

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Implementation Workstreams

• 3. Governance Structure
• Management of risks NB handovers and transfers of
  care
• Addressing different interpretations of risk
• Agreed standards and protocols
• Clear lines of management accountability
• Compliance with CSSIW regulatory requirements
• Compliance with health Clinical Governance
  requirements

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Implementation Workstreams

• 4. Outcome Indicators, Performance and Continuous
  Improvement
• Development of outcome indicators to ensure
  programme delivers what users want and associated
  monitoring arrangements.
• Development of business performance indicators
  and associated monitoring arrangements
• Feedback loop to ensure learning service
  improvement

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Implementation Workstreams

• 5. Information sharing Single Point of Access
• Develop agreed information sharing protocols
• Develop safe means of electronic transfer
• Develop the model for the Single Point of Access

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Implementation Workstreams

• 6. Locality Planning
• (including longer-term care and interfaces with
  other services)
• Using the outputs from the workstreams above to
  support planning for preventative services and
  delivery at locality level
• Ensuring that core standards are met and outcomes
  achieved whilst retaining local colour
• Identify local components of the Longer term
  Approach

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Implementation Workstreams

• 7. Financial Modelling/ Building the Business
  Case
• Using the engagement from the workstreams above
  to
• confirm demand
• map capacity
• identify the resource gaps
• calculate the financial requirements
• Pooled budget arrangements

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Key Milestones

• Strategic Outline Case submitted October 2009
• Groundwork from workstreams completed by end of
  March 2010
• Localities sign up and begin implementation from
  April 2010

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Contact details

• Lynda Chandler Programme Manager
• Lynda.chandler_at_torfaen.gov.uk
• Tel [phone]
• Mobile [phone]
• Website http//www.gwentfrailty.torfaen.gov.uk