Transcript Happily Independent’

‘Happily Independent’
Gwent Frailty Programme
Introductory Presentation
Updated November 2010
The Vision:
‘Help when you need it to keep you
independent’
The Ethos:
People are individuals with a life, a history
and a future;
They are the experts in their own life and
we need to tap into that expertise;
The present system is untenable & does
not treat people as well as we want it to;
We work best when we work together, with
shared values and joint outcomes that
keep the person at the centre.
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
Frailty Definition
Dependency
Chronic limitations on activities for daily living
With one or more physical, or social needs, including those
who have dementia
Vulnerability
‘Running on empty’
Usual coping mechanisms aren’t working
Co-Morbidity
E.g. People with a chronic condition who as a result may have
health, social care and/or housing needs.
Why Do it?
It’s 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 doesn’t deliver the goods.
Outcomes: what older people in
Gwent told 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.
And a bit of this……
• Be safe and secure
• Live in good quality homes
• Be able to cook, wash, clean
and go out
• Be able to maintain their
standards
• Be financially stable to make
independent choices
• Be receiving the benefits
available to enable them to
live independently
• Not be lonely
• Have a supportive family
• Have good friends and
neighbours keeping an eye
out for them
• Have company
• Be going out to social
activities
• Have planned for old age
• Be accessing peer support
• Be able to keep a pet if they
so wish
Integrated Locality Approach
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 Layers:
• Community
Resource Teams
• Training,
development,
cultural change
• Work with LSBs
etc
• Influencing &
aligning
What the CRTs will look like…
Integrated Community Resource Team Manger
Community Resource Team providing:
Urgent Comprehensive Needs Assessment
Rapid Response to health & social care need
Emergency Care at Home
Reablement
Falls
Chronic Conditions
Management
Continuing Health
Care
Palliative care
Long term care
Flexible health and social care ‘Support & Wellbeing’ workers.
Potential to work across teams & move through the system with the
individual to provide continuity
Wallace.,C, (2009) An exploratory case study of health and
social care service integration in a deprived South Wales area.
Integrated CRTs
providing support
to move individual
back to
independence
Active Service user
co-ordination
Independence
Carer co-ordination
control
Collaborative service
user/carer
relationship
Dependence
Team Composition:
It is proposed that each locality
team will include the following
members:
Administrative support
A team of Support & Wellbeing
Workers
Registered General Nurses
Registered Mental Nurses
Social Workers
Pharmacist
Specialty Doctors
Occupational Therapists
Physiotherapists
Dietetics/SALT/podiatry
Consultant
Physician/appropriate medical
input
Core standards
Single Point of Access
7 days a week 365 days a year
8am to 8pm as a minimum
2-4 hours response time (for both health and social care
urgent components)
Comprehensive Needs Assessment
Management/ Hospital @ Home for up to 14 days in
response to assessed need
Hot Clinics for rapid access to specialist and diagnostic
Rapid access to equipment and minor adaptations.
Up to 6 weeks reablement & review
Onward referral where required
Case Scenario 1
• Mrs Jones, a 45 year old lady with Multiple Sclerosis, develops
urinary symptoms. Her GP visits and treats Mrs Jones for a urinary
tract infection. 24 hours later however she is still not coping and is
‘off her feet’. The GP refers her, via the Single Point of Access, to
the Community Resource Team.
• They visit within the hour and assess her thoroughly. They exclude
other potential diagnoses and assess that Mrs Jones needs support
to help her recover. The registered nurse arranges for social care
and occupational therapy to help Mrs Jones get back to
independence as quickly as possible. A Support & Wellbeing
Worker visits 3 times a day to help Mrs Jones with her daily living
needs.
• After a week, the infection is resolved, but Mrs Jones is still
unsteady and lacking in confidence. Further reablement support is
developed by the therapists in the team and delivered by the
Support & Wellbeing Worker. A discharge letter summarising Mrs
Jones’ outcomes and onward referral is sent to her GP.
Case Scenario 2
• Mrs Jones is 70 years old and is bed
ridden. She is cared for by her husband
who is normally a physically fit 75 year old.
• Mr Jones develops chest pain and is
rushed to hospital by ambulance leaving
Mrs Jones alone. Mrs Jones is referred to
the Community Resource Team for
support during her social care crisis.
Story so far………
Established what older people want
‘Towards Independence for Older people in Gwent’
Articulated the vision
‘Happily Independent’
Achieved executive and political sign up to
the Strategic Outline Case
Seven implementation workstreams up
and running
Locality Implementation Groups set up
(Franchise Model)
The Workstreams:
Communication & Stakeholder
Engagement
Workforce Planning
Governance & Structures
Performance Management & Evaluation
Information Sharing & Single Point of
Access
Financial Modelling
Locality Planning
Other Task & Finish Groups
in progress…………..
Carers Strategy
Mental Health
Referral management (criteria, screening,
Frailty Index etc);
Out of hours/ On Call arrangements,
including cross-boundary cover at times of
peak demand.
Falls Strategy
Telecare
Locality Frailty
Implementation Groups
Each Borough to assess local need and
design their specific CRT in response,
e.g.
• Size/number
• Location
Invest to Save monies………
£9m over 2010/11 –
2012/13
Approximately £3m,
£2.3m, £3.7m
Non – recurring
funding = transfer of
resource
Payback of loan 5 – 7
years
Some conditions!
We have to shift resources from acute
care to community and eventually pay the
money back
We will enter formalised legal pooled
budget arrangements between NHS and
the 5 local authorities
We will subject ourselves to external
evaluation and share our learning (warts
and all!)
Savings from Frailty
Reduction in Acute beds = transfer/reduction in
staff
Reduction in Community beds =
transfer/reduction in staff
Reduction in Residential care beds =
transfer/reduction in staff
Reduction in domiciliary care packages
Staff travelling time using technology
Slower growth in number of complex care cases
What next…
Formal Staff Consultation during
November and December; all staff
will know where they will be and
what they will be doing, by
Christmas
All local implementation plans
reviewed and finalised by December
CRT Managers appointed by January
What next…
Boards and Cabinets sign off final plans in
January
CRT staff preparation/induction training
January to March
Formal budget agreements signed off
February
IT and Single Point of Access systems
tested before March
What next…
End of March all CRTs co-located and
systems ready.
Go live 1st April 2011
Contacts:
Programme Managers:
Lynda Chandler –
[email protected]
Tel: 01495 742411
Gill Lewis –
[email protected]
Tel: 01633 623828
Website:
http//:www.gwentfrailty.torfaen.gov.uk