Cimla Health and Social Care Centre 26 th November 2015 Presented by: Louise Barry Head of Integrated Community Services Andrew Griffiths - Integrated Community Services Manager Sarah Waite Community Resource Team Support Manager
Workshop Objectives Brief History of Cimla Hospital From Hospital to Health and Social Care Centre Challenges Lessons Learnt Opportunities for the future
Cimla Hospital Established Community Hospital Housed two wards: Brynedd a intensive rehabilitation ward Glannant a medically acute ward In the autumn of 2013, the health board confirmed the last remaining ward at Cimla would move to Neath Port Talbot Hospital. This was to allow patients to benefit from 24-7 staffing and improved access to diagnostic and clinical supervision of care.
Cimla Health and Social Care Centre
Services Based within the Centre Neath Network Adult Social Care Team Neath Network District Nursing Team Adult Safeguarding Team Adult Commissioning Team Western Bay Substance Misuse Team Community Health Council Lymphoedema Clinic The Gateway The Community Resource Team Community Occupational Therapist Acute Clinical Team Assistive Technology Education Programme for Patients Facing the Challenge Carers Service Demonstration Centre Social Enterprise
How did we do it?
Western Bay Collaborative Western Bay partners made a statement of intent to work in an integrated way to meet the needs of older frail people. Sept 2013 Joint commitment signed off by 3 Cabinets and the Health Board. One year, one off Welsh Government Intermediate Care Fund investment of 7.8m for 2014/15 to further enhance integrated working and work towards establishing pooled budget (Section 33 agreement).
Western Bay Community Services (Older People) Project Community Services Project was developed as a whole system response to scaling up intermediate tier services and is underpinned by a strategic business case. Intermediate Care is where most integration already occurred, so it made sense to start here Statement of Intent. ICF allowed us to escalate the pace of our business case.
Care and Support for Frail Older People Overarching Model
Phase 1: Intermediate Tier Common Access Point Third Sector Brokerage Patient Service User Rapid Response Service Reablement Step Up / Step Down Assessment Support and Stay (mental health)
Intermediate Tier S33 Section 33 covers the following intermediate care functions: Common Access Point NPT Gateway Rapid Response Acute Clinical Team Planned Response: Reablement Service CRT Social Work Team Residential Intermediate Care Beds Medicines Management Team Assistive Technology Team The s33 is both practical and symbolic Performance schedule is specified Budget is set and reviewed on an annual basis in the context of organisational NPT CBC is the lead for the proposed s33
Intermediate Tier Business Case Intermediate Tier Business Case was based on an optimal model this was described, not prescribed Disparate starting points across the 3 areas Local governance determined exact workforce profiles 47 staff recruited A full time community consultant Benefits were modelled to be achieved 6 months after full capacity in place NPT are now close to the optimal model We are working closely with colleagues in MH to integrate services and functions.
Key Messages There is evidence the intermediate tier is having a positive impact on system performance reduction in care home admissions reduction in acute admissions reduction in domiciliary care packages Performance is significantly better than the do nothing scenario within the business case The governance and accountability for delivery has been located at local level, rather than a Western Bay level. ABMU work in NPT virtual ward of 35 bed equivalents in community
What next? Increasing from the provision of Intermediate Care beds from November 2015. Integrating Older Person s Mental Health services with Community Services and within the Gateway.
Phase 2: Network Integration & Anticipatory Care Focus on the needs of older people at risk of losing their independence Plan and implement community services around the 3 Community Networks Focus on early intervention and prevention to tackle loneliness and social isolation Core community services will deliver pro-active anticipatory care planning Services will be integrated on the basis of only doing things once where possible Integrating Older People s Mental Health in a team around the person approach
What we will do We will use innovative ICT solutions to give the workforce the tools they need to do the job We will develop our workforce through team development and leadership for staff moving to a core competency framework We will work with third sector to build the infrastructure needed in communities to support people We will minimise delays for patients who have had unplanned admissions to hospital by improving the interface between community services and hospitals
Anticipatory Care Mrs Edwards Doesn t want help Anxious Forgetful Struggling to cope Depression High Anxiety Doesn t know who to turn to Mrs Edwards Betty her daughter/sole carer
Anticipatory Care Model CPN Care Co-ordinator Dementia Diagnosis (Consultant Psychiatrist) Dementia Care-coordinator providing support 2 x Weekly Satellite clubs (CPN/ OT) Small Package of Care (Social Worker) Carers Support Group (3 rd Sector)
Outcomes
Anticipatory Care One Person holds the RING Anticipatory Care Plan in place...we know what to do in a crisis Empowered to cross commission what is needed Nurse, LAC, Care, Short Break Avoids duplication, hands off and chaos Mrs Edwards and her daughter only have one number and one person to support them
What Matters to Me.
Challenges IT the integration of 2 systems Organisational Development Language and Understanding of integration across services Clarity of the aims of the new service model Performance Management
Lessons Learned Just do it Find the things you can agree on and start your project from that point Start small, with actions rather than detailed plans Effective relationships trusting and empowering staff to do the right thing
Lessons Learned Cont... Workforce stability and leadership Develop outcomes that meet the needs of individuals and keeping them simple Sign up from all organisation Don t wait for the IT system to be suitable for purpose you ll be waiting along time