gwent frailty programme ‘happily independent’ a brief overview of the vision
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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 social care deliveryRepresents 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 doesn’t deliver the goods.
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
What do we mean by ‘frailty’?Dependency
Chronic limitations on activities for daily livingWith one or more functional, cognitive or social
impairments
Vulnerability‘Running on empty’
An overall loss of physiological reservesLoss of functional stability
Co-morbidity
E.g. Older people with chronic condition (Health and social care needs)
What we stand for:Principles & 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.
Outcomes:What 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.
Wallace.,C, (2009) An exploratory case study of health Wallace.,C, (2009) An exploratory case study of health and social care service integration in a deprived South and social care service integration in a deprived South
Wales area.Wales area.
Carer co-ordination control
Active Service user co-ordination
Collaborative service user/carer relationshipIndependence Dependence
Community Resource Teams
providing support to move individual
back to independence
Frailty Programme layers of Activity
Community Resource Teams in each Borough to bounce people away from crisis and the dependency spiral, back to
a place where they can be supported to be ‘happily independent’.
Seven Implementation Workstreams to support effective implementation of the above
Training, Development and Cultural Change Management Programmes with the staff both in the Intermediate Care Teams and in the wider health and social
care community to promote the ethos of sustaining independence
Work with Local Service Boards to ensure that other supporting factors for sustaining independence are provided e.g. access to
adequate housing, benefits, community safety etc.
Influencing and aligning with developments in the wider Community Based Services, to ensure that the Frailty Programme is a catalyst for
change and not simply and ‘bolt on’ set of services.
The Locality Model:A 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)
Integrated Locality Model
Acute
Intensive packages
Episodic or longer
Term interventions
Identified needs warranting integrated approach
Some identified health/social care
needs
Preventative Services
Community Context
Frailty Programme Priorities 2009/11
Implement Service Models For:
• Urgent Assessment and Intervention;
• Independent Living & Reablement;
• Including interface with CHC, CCM and core services;
How they’ll fit together :
Flexible health and social care ‘Care & Wellbeing’ workers.
Potential to work across teams & move through the system with the individual to provide continuity
CCMCHC
Palliative careLong term care
Community Resource Team providing:
Urgent Comprehensive Needs AssessmentRapid Response to health & social care needEmergency Care at HomeReablement
Integrated Community Resource Team Manger
Common Service Characteristics:
Access
Hours of operation
Response time
Comprehensive needs assessment
Service provision
Access to other specialities
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.”
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.
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
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 GP’s and practice staff in location.
What the Integrated Community Resource Team will look like:It is proposed that each locality
team will include the following members:
Administrative supportA team of Care & Wellbeing Workers Registered General NursesRegistered Mental NursesSocial WorkersPharmacistSpecialty Doctors
Occupational Therapists
Physiotherapists
Reablement Nurses
Social WorkersReablement AssistantsSenior Reablement AssistantsConsultant Physician
Next Steps
Service Model
Capacity Plan
WorkforcePlan
Plan
Service Model
Capacity Plan
WorkforcePlan
FinancialPlan
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
Implementation Workstreams2. 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
Implementation Workstreams
3. Governance & Structure
Management of risks NB handovers and transfers of careAddressing different interpretations of riskAgreed standards and protocolsClear lines of management & accountabilityCompliance with CSSIW regulatory requirementsCompliance with health Clinical Governance requirements
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 arrangementsFeedback loop to ensure learning & service improvement
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
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 levelEnsuring that core standards are met and outcomes achieved whilst retaining ‘local colour’Identify local components of the Longer term Approach
Implementation Workstreams
7. Financial Modelling/ Building the Business Case
Using the engagement from the workstreams above to:confirm demandmap capacity identify the resource gapscalculate the financial requirementsPooled budget arrangements
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
Contact details
Lynda Chandler: Programme Manager
• Tel: 01495 742411
• Mobile: 07939618877
• Website: http://www.gwentfrailty.torfaen.gov.uk