Title: Gwent Frailty Programme
1Gwent Frailty Programme
- Happily Independent
- A Brief Overview of the Vision
2Why 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.
3Why 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
4What 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)
5What 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.
6OutcomesWhat 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.
7Wallace.,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
8Frailty Programme layers of Activity
9The 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)
10Integrated Locality Model
11Frailty Programme Priorities 2009/11
- Implement Service Models For
- Urgent Assessment and Intervention
- Independent Living Reablement
- Including interface with CHC, CCM and core
services
12How theyll fit together
Integrated Community Resource Team Manger
13Common Service Characteristics
- Access
- Hours of operation
- Response time
- Comprehensive needs assessment
- Service provision
- Access to other specialities
14Urgent 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.
15Independent 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.
16Independent 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
17Independent 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.
18What 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
19Next Steps
Capacity Plan
Service Model
Financial Plan
Workforce Plan
20Implementation 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
21Implementation 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
22Implementation 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
23Implementation 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
24Implementation 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
25Implementation 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
26Implementation 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
27Key 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
28Contact details
- Lynda Chandler Programme Manager
- Lynda.chandler_at_torfaen.gov.uk
- Tel 01495 742411
- Mobile 07939618877
- Website http//www.gwentfrailty.torfaen.gov.uk