Primary and Community Services Strategic Delivery Programme

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Local Service Board Health and Social Care
Innovation Network
25th November 2009
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Neath Port Talbot LSB

• Identified the Delivering Integrated Services
  Project as an LSB project.
• Key elements of the Project for NPT
• Development of a Community Integrated
  Intermediate Care Service. ( CIIS)
• Pilot of Lifestyle Coaches, Directory of Services
  and University Evaluation

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Principles of Intermediate Care

• Targeted to avoid unnecessarily prolonged
  hospital stays or inappropriate admission to
  acute in-patient care, long term residential
  care, or continuing NHS in-patient care
• Provided on the basis of a comprehensive
  assessment, resulting in a structured individual
  care plan that involves active therapy, treatment
  or opportunity for recovery
• Has a planned outcome of maximising independence
  and typically enabling patient/users to resume
  living at home
• Can be time-limited, based on an identified and
  assessed need
• Involves cross-professional working, with a
  unified assessment framework, single professional
  records and shared protocols.

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Pathway Pre- CIIS
Hospital Referral
Community Referral
Referral to individual teams e.g.
Reablement Service
Adult Disability Team
ERS
COPD
Enabling home care
Rehab teams
Rehab beds
Stroke
Heart failure
Assessment Intervention by individual teams
Onward referral or discharge. Inc Referral
between teams
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Community Integrated Intermediate Care Service
Community Referral (HV, DN, GP, Com pharmacy,
AHP, SW
Hospital Referral / Ambulance
PRISM
Single Referral Point
Disease specific with agreed ICPs
Generalist' IC services.
Community Integrated Intermediate Care Service
(CIIS)
Flexible Support Workers
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Improvements Benefits

• Patient centred not service led
• Reduced number of interfaces
• Eliminates duplication of effort
• Improved transfer of information
• Improved coordination between teams
• Increased capacity
• Reduced service shortfalls as flexible response
  offered
• Increased skill mix
• Economies of scale
• Flexible workers to improve coordination
• Team Focused

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Potential

• Whole systems approach to the provision of
  community services linking early intervention
  services, day services, rehabilitation services
  and chronic disease management
• Opportunity to improve joined up working with
  person and family/carer centred approach to
  assessment and integrated health social care
  interventions
• Links to telecare assessment, falls service,
  enabling home care, day services, voluntary
  services, mental health services.
• Maximise opportunities and help people achieve
  the highest level of independence
• Seamless transition of care

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Development of CIIS An Example
CIIS Operational Manager
Intermediate Care Single Point of Referral
Integrated Management And Administration

Telecare/Telehealth
HEAT (SSs Assessment Team)
Reablement
ERS
Specialist Community Nursing
Enhanced Sensory Impairment Services
Social Work
Rehabilitation Officers
Speech and language therapy
Occupational therapy
Community support workers
Physiotherapy
Integrated CIIS Support Workers
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OVERALL MESSAGES

• Sustainability of existing investment reliance
  on short term, grant funding
• Needs greater awareness of services available to
  all professionals and robust governance
  arrangements
• Specialist community teams need to be realigned
  to bring full benefits
• Single point of access and communication hub
  essential to realise full benefit of model
• Requires alignment with unscheduled care eg GP
  OOH, MIU, AE to divert patient
• Need timely access to community equipment to
  enable patients to be maintained at home

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Benefits through being an LSB project

• Support from WAG when allocation of funding was
  in doubt.
• Higher profile to the initiative in NPT than in
  neighbouring areas with cross agency
  understanding and support.
• Support from the LSB for this scheme being
  prioritised for grant applications

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Delivering Integrated Services Project Self
Care, Prevention and Promotion An Evaluation
of the Lifestyle Coach Pilot

• Over half of what affects peoples
• health is their choice of lifestyle
• (Arlosk 2007)

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Project aims
improve health and wellbeing of
people with chronic conditions by
supporting them to make the best use of their own
and the communities resources by developing
a model based on the co-production of health,
which requires peoples to take
responsibility for optimising their own health
and supporting them to develop the skills
and access the resources to do this
successfully
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CRITERIA
Individuals had to be over the age of 50,
diagnosed with arthritis or a significant
musculo-skeletal problem, and considered to have
the potential to benefit from the
intervention.
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Skills of Lifestyle Coaches

• ? Motivational Skills
• ? Communication Skills
• ? Behavioural Change Skills
• ? Engagement Skills
• ? Signposting Skills
• ? Evaluation Skills
• ? Data Collection and Analysis Skills

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Age Profile of Clients
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Outcomes

• Dimension (EQ-5d) fewer problems more problems
• Mobility 8 6
• Self Care 15 3
• Usual Activities 28 3
• Pain/Discomfort 27 8
• Anxiety/Depression 38 5

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COMMENTS RECEIVED the opportunity to talk
freely with a professional who had the background
and knowledge to give advice and recommendations
having time to discuss various health issues
this cannot be achieved with a five minute
doctors appointment it has helped me think
much more about my future health and that actions
today will seriously impact on it her
personality is vibrant and positiveher
information is straight forward and easy to
understand. You leave feeling positive
talking and learning about my condition
talking to someone with knowledge of
facilities and opportunities in the area to
increase fitness it has enabled me to
talkabout all my feelings and anxieties far more
than I could to my friends and family it
focused my mind on actually making an effort to
do what I had been thinking about for some time

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POSITIVE OUTCOMES I was very low when I
first saw the coachwithin 8 weeks my full
confidence has returned an excellent
experiencemy wish is that she would stay at our
surgery feel normal after consultations
I think this is an excellent service in that
it could save the health service a great deal of
future problems and expenditure by its proactive
approach this is a truly excellent service.
The very best I think this is a vital service
for patients with disabilities, who have
difficulties leaving the house because of lack of
knowledge of the facilities in the area
having it at my local doctors was very
convenient a great opportunity for anybody
with a need to discuss problems which GPs dont
have time for
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Benefits of being an LSB pilot

• Support from WAG representative on LSB to
  expedite a response from MtC fund.
• Positive involvement in key groups within NPT
  e.g., Health, Social Care and Wellbeing.
• High profile support across agencies