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Gwent Frailty Programme

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Gwent Frailty Programme Happily Independent A Brief Overview of the Vision Why do it? It s what older people tell us they want! Integrated model of health and ... – PowerPoint PPT presentation

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Title: Gwent Frailty Programme


1
Gwent Frailty Programme
  • Happily Independent
  • A Brief Overview of the Vision

2
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.

3
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

4
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)

5
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.

6
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.

7
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
8
Frailty Programme layers of Activity
9
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)

10
Integrated Locality Model
11
Frailty Programme Priorities 2009/11
  • Implement Service Models For
  • Urgent Assessment and Intervention
  • Independent Living Reablement
  • Including interface with CHC, CCM and core
    services

12
How theyll fit together
Integrated Community Resource Team Manger
13
Common Service Characteristics
  • Access
  • Hours of operation
  • Response time
  • Comprehensive needs assessment
  • Service provision
  • Access to other specialities

14
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.

15
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.

16
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

17
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.

18
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

19
Next Steps
Capacity Plan
Service Model
Financial Plan
Workforce Plan
20
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

21
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

22
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

23
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

24
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

25
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

26
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

27
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

28
Contact details
  • Lynda Chandler Programme Manager
  • Lynda.chandler_at_torfaen.gov.uk
  • Tel 01495 742411
  • Mobile 07939618877
  • Website http//www.gwentfrailty.torfaen.gov.uk
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