CONWY INTERMEDIATE CARE SERVICE

Glynis TabbererIntermediate Care Service manager

Conwy & Denbighshire NHS Trust

BACKGROUND

The Maintaining Independence Project Board a multi-agency group set up in Conwy in February 2005 including:

local authority health voluntary organisation service user representatives

FUNDING FOR THE PROJECT

Wanless Ref: “The Review of Health and

Social Care in Wales”

Review existing provision Develop the availability of I.C. in

Conwy

WORKSHOP

In April 2005 “The Maintaining Independence Project Board”

to involve vital stakeholders in the development which was focused on:

need pan Conwy sustainable achieves the intended outcomes reducing acute demand maintaining people in their own homes.

RECOMMENDATIONSGroup Staffing

Multi-disciplinary Team consisting of: Nurse Assessors Social Workers Occupational Therapy Physiotherapy TI3 Rehabilitation Assistants Support Workers Medical and Pharmacy support

RECOMMENDATIONS

Service Hours

the service becomes a 7 day a week service Monday-Friday with full cover weekends with skeleton staff coverage to

allow for emergency situations e.g. use of step-up beds, planned discharge for weekends etc

RECOMMENDATIONSService Characteristics

Two separate rapid response teams Geographical gap

It was recommended that the intermediate care service would be:

Pan Conwy One team managed by one division within the

Conwy & Denbighshire Trust Combined services ensuring that their current

best practice was not lost Service would also include access to step up

and step down beds

RECOMMENDATIONS

Eligibility Criteria

The service was targeted at the elderly, over 65 years of age, and registered with a Conwy GP

Aged over 18 years old A resident of Conwy Not requiring acute inpatient episode

RECOMMENDATIONS

Access to service Referrals made by an appropriate

professional - health or social care Development of additional community

based services across the whole county Improving patient flow through the health

and social care system The development of staff to meet the

challenges of Intermediate Care The introduction of a single point of referral

CONWY INTERMEDIATE CARE SERVICE (C.I.C.S.)

April 1st 2006 The amalgamation / re-configuration

of: the Conwy Rapid Response

Rehabilitation Team, Colwyn Bay Elderly Care Assessment Team,

Abergele

Geographical Gaps

Original areas covered

Population 18,753 aged 65+

91,000 – aged 18+

Potential increase in population of 72,247

Increased Staffing Resources

Intermediate Care Services Manager TI3 Rehab Assistant Physiotherapist Occupational Therapist Home Care Co-Ordinator Social Worker Support Workers CPN

WORKING SEAMLESSLY ACROSS ORGANISATIONS

The CICS team promote working in partnership with:

The Voluntary Sector Social Services Department Local Health Board Primary and Secondary Care

WORKING SEAMLESSLY ACROSS ORGANISATIONS

The Health Precinct partnership project currently

underway create seamless joint working

between Conwy & Denbighshire NHS Trust Conwy County Borough Council Social Services

HEALTH PRECINCT an accessible place rehabilitation and the return to fitness is

integrated activity related to the promotion of good

health partnership working leisure and health staff can collaborate develop innovative and effective physical

activity interventions for the management of chronic disease conditions

HEALTH PRECINCT

100 pieces of state of the art 'Technogym' cardio and resistance equipment

Swimming pool Enlarged changing

room facilities for sport and activities

Tennis centre Bowling greens Indoor bowling

Swimfit yoga, pilates,

aquarobics and circuits Badminton, squash,

athletics etc Golf Walking in the Park Consulting rooms Car parking Public transport links

The new facility will provide the following:

G.P. REFERRAL SCHEME to provide supervised safe physical activities a number of group based activity options

made available during the 16 week programme

monitored though progress reviews which are used to motivate and encourage

concept will build upon current services The Welsh Assembly is offering support

through funding scheme will be evaluated by Cardiff University

SERVICE EVALUATIONKey Performance Indicators KPI's were developed in 2006 using the balanced

score card method the ICD 10 coding system to calculate an

average length of stay 1st Jan - 11th Feb '08 of 389 bed days saved

The methodology has been validated by: the head of Information, Planning and

Performance Management consultation with the Clinical Coding Manager the Information department.

FACILITATE EARLY DISCHARGE

the ICD 10 coding system compared against the actual

number of days that homeward bound patients remain in hospital

the patient's admission date and average length of stay for each individual's condition

Predictive date of discharge (PDD)

Mapping Conwy Intermediate Care Services

A&E /AMUAdmissions

Acute Care Wards

Acute care ofadults

Otherspecialities

Stroke unit/ward

Generalmedicine

Intermediate care incommunity hospital

Step-up/step-down bedsIntermediate care in the community

At home withactive rehab/

support

Short stay inresidentialcare home

Short stay innursing home

Short stay inextra carehousing Long-term (institutional) care

Residential care home Nursing home NHS long-term careDied

Key:Institutional care

Intermediate Care

Home(not admitted)

Home withcare package(not admitted)

Rapidintervention

CommunityMental Health

Team

Outpatientsclinics

Supporteddischarge

Home withcare package

(post-treatment)

Home(post-treatment)

G.P.Palliativecare team

HealthPromotion

Pharmacysupport

Healthvisiting

PodiatryPracticenursing

Nursespecialists

COPDOP’sParkinson’sStroke, etc.

Occupationaltherapy

PhysiotherapyDiateticsSpeech &

language therapyPrimary care services

District Nursing

ShoppingService

Home careRehabcare

assistants

SocialWork

Nightsitting

Aids todailyliving

Jointequipment

store

Extra homecare/personal

care assistants

PsychologyCommunitypsychiatric

nursing

Communityalarm

Smart housinginc Telecare

Care &Repair

Homeadaptations

Shelteredhousing

Day careMeals onWheels

CounsellingAdvocacy

Money adviceGeneral info/advice

Age ConcernStroke

AssociationSaafa/British

LegionBritish Red Cross

Cais Cinnamon Trust Crossroads

CommunityTransport

Help the Aged

Carers Outreach

Cruse

Community Health & Social Care(I.C. supported)

Voluntary Organisations(I.C. supported)

LESSONS LEARNED The importance of good change

management skills Clear access criteria Clearly defined Performance Indicators A robust evaluation tool which identifies

subjective outcomes Introducing the single point of referral Identification and development of existing

services linking to I.C.

And finally

Any Questions?