CONWY INTERMEDIATE CARE SERVICE Glynis Tabberer Intermediate Care Service manager

1. Conwy & Denbighshire NHS Trust CONWY INTERMEDIATE CARE SERVICE Glynis Tabberer Intermediate Care Service manager

2. 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

3. 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

4. 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.

5. RECOMMENDATIONS Group Staffing Multi-disciplinary Team consisting of: • Nurse Assessors • Social Workers • Occupational Therapy • Physiotherapy • TI3 Rehabilitation Assistants • Support Workers • Medical and Pharmacy support

6. 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

7. RECOMMENDATIONS Service 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

8. 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

9. 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

10. 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

11. Original areas covered Population 18,753 aged 65+ 91,000 – aged 18+ Potential increase in population of 72,247 Geographical Gaps

12. Increased Staffing Resources • Intermediate Care Services Manager • TI3 Rehab Assistant • Physiotherapist • Occupational Therapist • Home Care Co-Ordinator • Social Worker • Support Workers • CPN

13. 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

14. 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

15. 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

16. 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 HEALTH PRECINCT The new facility will provide the following:

17. 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

18. SERVICE EVALUATION Key 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.

19. 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)

20. Mapping Conwy Intermediate Care Services

21. 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.

22. And finally Any Questions?