Delivering the Gwent Frailty Programme 7 days a week

The Pan Gwent Frailty Model

Happily Independent

What is frailty

• Mainly, but not exclusively, age related

• Limitations on the ability to deal with daily life without support

• Multiple impairments or disabilities

• “Running on empty” with low psychological reserves

• One or more chronic medical conditions

The present system was broken and unsustainable

• Process driven for the comfort and convenience of organisations, professions and specialisms – citizen not at the centre

• Unnecessary hospital admissions e.g. falls• Delays in A&E and Medical Assessment Units resulting in

rapid loss of independence• Lengthy hospital stays and delayed transfers of care• Institutional care as a default solution• Too much money invested badly in acute services and

underinvestment in support and prevention • People treated by illness not holistically

How the frailty programme came about

• Meeting of the, then, 11 Chief Executives in October 2007• Strategic focus on older people as a key area of high spend for

health and social care• Workshops with front line managers and clinicians across

localities and agencies• New model of service provision developed around rapid crisis

intervention and reablement based on one key outcome – “Frail people are happily independent”

• Programme Board set up and Programme Manager appointed

The impact we need

• Better outcomes for frail people and their families• Fewer acute hospital admissions• Shorter stays in hospital• Fewer delayed transfers of care• Improved flow through secondary care services• Reduced hospital acquired infections• 24/7 access to community services• Reduced demand for complex care packages• Reduced demand for Continuing NHS healthcare• Better use of public money

Core Requirements

• Referral via single point of access – SPA recording and holding multi agency data centred on the patient

• Only professionals can refer at present (GPs, nurses, social workers, ambulance service etc)

• 8.00am to 8.00pm 365 days a year• Multi agency community resource teams• Response within 4 hours for rapid urgent medical/social care

response• Up to 6 weeks of free rehabilitation plus onward referral• Falls management and prevention

The Story so far

• Commenced April 2011• All Community Resource Teams co-located and fully

integrated• Generic “support and wellbeing” workers• Integration of community occupational therapists• ICT systems allowing staff to share information across

organisations and professionals• Reduction in bed days without increase in delayed transfers

of care• Falls assessment and prevention services developed

2012/13 Activity – 12,498 cases

CRT Activity 2012/13

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Financial Framework

• Declarations– Current services & Resources invested– £8.6m across Gwent

• Estimated Future requirements– Investment plans to meet frailty standards– £6.9m across Gwent

• Future total service resources– £15.5m– Managed via section 33 pooled fund

Savings needed from investing in Savings needed from investing in FrailtyFrailty

Reduction in Acute beds Reduction in Community beds Reduction in Residential care beds Reduction in domiciliary care packages

Reductions = staff and non pay SHIFT

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2010-11 2011-12 2012-13 2010-11 2011-12 2012-13 2010-11 2011-12 2012-13 2010-11 2011-12 2012-13 2010-11 2011-12 2012-13 2010-11 2011-12 2012-13 2010-11 2011-12 2012-13

0-2 Days 3-5 Days 6-10 Days 11-14 Days 15-21 Days 22-49 Days Days 50+ Days

Something is going on: A&E Presentation YTD comparison

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Very good feedback

• March 2013 review by Community Health Council• Survey of 1200 users• 76% of users/carers very appreciative of the service• More compliments than any other service provided

by ABHB• Staff passionately believe in the service and are

highly motivated

Lots still to do• Balance of admission prevention/pull not right yet• Franchise model needs to conform to core standards; noone does

totally at present• 7 day cover from clinicians• More consistent use of nursing skills• Some GPs still resistant to/having problems with referring• Need better take up from ambulance crews• Unpredicted levels of demand are outstripping predicted savings in

acute/institutional care and hence payback of invest to save. Not enough bed day reductions to meet the business case

• Technology still needs refining

Any Questions?