Transcript CCM Demonstrator Learning Event

Mainstreaming the Carmarthenshire approach to Chronic
Conditions Management across Hywel Dda
Kathryn Davies
Director - Therapies and Health Science
Key Features
• Designed to deliver services to meet citizens’ needs and
support self management, prevention and early
diagnosis
• Joint health and social care locality management and
service structure
• Led by co-located community clinicians and social care
practitioners
• Single entry point
• Shared information with service user permissions
• Performance management framework
Principles
• Risk stratification – to proactively target service
users at risk across all 4 levels
• Supporting people to self manage wherever
possible
• Providing appropriate services that meet citizens’
needs closer to their home setting
• Developing the workforce and tools to ‘push’ and
‘pull’ service users along pathways
• Designing care pathways across the continuum of
service delivery irrespective of care setting
Outline of geographical localities
Sheep
Coal
Steel
3Ts
Aman Gwendraeth
Llanelli
Geographical
size
81%
14%
2.5%
Population
60,617
55,551
60,617
Services Gap Some key
services, eg
care homes in
Ceredigion
Aman > services
than Gwendraeth.
Service Users
access services in
other localities
No community
hospital
Needs
Prevalence
Highest chronic
disease and social
need prevalence
Prevalence equally
distributed amongst
GP practices
Higher % of
older people
Translating the CCM model & framework into action
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Integrated Locality Leadership Groups – included in Carmarthenshire County Organisational Structure
consultation document:
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GP
Social Services Area Manager
Community Nursing lead
Care Services Planning Co-ordinator
Core CCM Team / Community Resource Teams co-locating the following staff:
– Social Work
– Enablement
– Domiciliary Care
– Chronic Disease Management
– Occupational Therapy
– Physiotherapy
– Disability
– Named network links and hot desk facilities for:
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District Nurses
GPs
Public Health Wales
Continuing Care Team
Housing Officers
Consultants
Acute Response
Multi-disciplinary team working for clients with complex needs
Partnership working and service improvements
CRT
Discharge
Transport
Pain Management
Telehealth and Telecare
Acute Multi-Agency Support
Team MAST)
Enablement Team
GP admission to Convalescence Beds
Immediate Response night care service
COPD pathway, Generic Support Worker
Lifestyle Adviser
Third Sector Services
Health, Well-Being & Support Directory
Information Sharing
Communications Hub
Partners
Service Users
Local Authority
Health Board
NHS Direct Wales
Public Health Wales
Third Sector
Communities First
NLIAH,
GP Practices
Outcomes for Patients
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Ease of access – one telephone number
Whole person / holistic approach
Effective triage / allocation system linking to priority of client
Reduction in routine information giving
Access to a nominated ‘key worker/care co-ordinator’
MDT for people with complex needs
Development of services within communities in response to needs
Continuity of care
Improved support for informal carers
Specialist services more accessible in the community
Care closer to home
Greater community cohesion
Benefits for Staff and Organisations
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Streamlined workflow
Improved Information sharing
Reduction in duplication
Integrated health and social services management structure
No ‘dumping’ policy
Services provided on the basis of need rather than meeting ‘criteria’
Opportunistic dialogue
Better knowledge of what’s available and therefore better advice offered
Better inter-professional working =
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Informal training & increased knowledge
Better shared workload
Opportunity to make a difference
Less onward referral – professional ownership
Better informed staff - creation of ‘whole team education & training opportunities’
Team ownership
Opportunity to develop UAP & joint systems