Cwm Taf Social Services and Wellbeing Partnership Board

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Organisations: Cwm Taf University Health Board, Merthyr Tydfil County Borough Council and Rhondda Cynon Taf County Borough Council

Title: Cwm Taf: STAY WELL IN YOUR COMMUNITY - Seamless services, closer to home, transforming outcomes.

Organisation Lead Contact:

Clare Williams – Assistant Director of Planning and Partnerships

STAY WELL IN YOUR COMMUNITY – Technical Appendix Jan 2019 Introduction Cwm Taf Social Services and Wellbeing Regional Partnership Board (RPB) has approved a whole system population health and social care model which responds the voice of the individual through three interwoven layers:

Wellbeing

Integrated Community Care, Closer to Home

Acute Health and Social Care and Tertiary Health Services

Scalability Whilst the Cwm Taf Regional Area Plan describes the steps being taken to improve outcomes across the whole model, this first tranche of our transformation proposal focuses on scaling up, and crucially linking, pilots which have already delivered proven benefit across Cwm Taf within the Integrated Community Care, Closer to Home layer. These are:

Risk Stratification and Segmentation – the current pilot in the Rhondda Cluster is developing a population health profile by linking and analysing primary and secondary care data in order to segment the cluster population into distinct groups based on their collective characteristics. In addition, risk stratification is being used to calculate individual patient risk scores using a wide range of modifiable and non-modifiable factors.

Cluster Focused Multi-Disciplinary Teams – a ‘Virtual Ward’ approach has been piloted in Cynon Cluster. A multi-disciplinary, anticipatory Primary Care, Welsh Ambulance Services Trust and Third Sector approach has been taken to providing support to the top 3% of service users in a GP practice, reducing demand on general practice both in and out of hours and on A&E. There is a dedicated MDT meeting on one day a week to design and implement care plans, with delivery taking place over the remaining four days of the week from the team and the GP practice.

Stay Well@Home – in response to growing pressures in A&E departments and the challenge of appropriate patient flow, integrated multidisciplinary teams, working 8.00a.m. - 8.00p.m,

Annex B4

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seven days a week, have been introduced in Prince Charles and Royal Glamorgan A&E, Acute Medical Unit and Clinical Decision Unit departments. These Cwm Taf wide Stay Well@Home teams of Social Workers, Occupational Therapists, Physiotherapists and Therapy Technicians work together promoting a "fit to assess” and “discharge to assess” model with the aim of identifying people earlier in their hospital journey who could be better supported at home. A ‘single’ ‘What matters’ conversation is undertaken, in line with the Social Services and Wellbeing Act (Wales) and Prudent Health to identify any unmet care and support needs. Each team member is a ‘trusted assessor’ who, following an assessment can directly commission a range of community responses tailored to the person’s needs. Direct, rapid response (typically 4 hrs) pathways to community services have been developed to support the hospital based team, which included the introduction of new services/enhancement of existing health, social care and third sector services to provide a supported seven day response.

As partners, we are uniquely placed to act as a pathfinder to inform wider health and social care planning and we are already sharing learning from the existing pilots with other regions. We are currently working with the Association of Directors of Social Services Cymru (ADSSC) Delivering Transformation Programme team within their Innovative Care Delivery Models in the Community Workstream which aims to develop practical guidance which will be helpful to other localities in taking forward a similar successful projects/model/ approaches. As we develop and test at scale a new system of seamless service, formal evaluation and dissemination will allow implementation at pace across other regions, empowering staff at Cluster and Locality level to transform the way they work and the services they provide. Evaluation As a consequence of our pilot study work, we recognise the importance of a carefully considered approach to evaluation that involves both summative and formative components and which accompanies the development of the initiative. We are also aware of the need to ensure that evaluation considers what outcomes or impact we propose to demonstrate with our transformation proposal and that these form the focus for the summative component of our evaluation. This is important as the question of sustainability of initiatives is inevitably high on our collective minds and we expect that a robust approach to framing and delivering the evaluation will inform how we go about embedding whole or selected aspects of this proposal. We have set out key deliverables and intended outcomes for specific components of our proposal. Our evaluation framework incorporates these and will involve a formative component that evolves with the implementation as well as a summative component that asks - ‘did we achieve the outcomes we set out to achieve?’ To this end, we are developing in-house capacity for evaluation through our local public health team. Crucially too, we are developing new academic collaborations with Cardiff University and Cardiff Metropolitan University to enhance our overall capacity to evaluate this initiative comprehensively, learning from it and shaping ongoing delivery and future mainstreaming. Finally, we will establish a collaborative approach with ICHOM (International Consortium for Health Outcomes Measurement) to develop a value-based health framework for delivering the triple aim components of the ‘quadruple aim’ (improve population health, improve quality/patient experience and reduce cost per capita of care). We will commission ICHOM to assist us with working with both clinicians and service users to develop appropriate outcome measures for the out of hospital developments we are implementing. The approach we are deploying to the transformation of our health and care services is one that is based on a data-driven profiling of our population to understand the natural clusters of persons in segments defined by care need rather than by disease

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condition, exclusively. These segments present a novel natural grouping within which to measure baseline and post-intervention costs and outcomes. While ICHOM’s standard outcome sets are currently largely disease-based, there is a good opportunity here to explore development of segment-based standard sets for outcomes based on and, in turn, informing our evaluation framework. We will commit funds to developing this collaborative work with ICHOM as part of our evaluation approach and commit to accompanying the outcome standard set development with segment-based measurement of costs in order to create a novel value-based health framework that will no doubt be useful on a national scale. Our current draft outcomes framework is as follows:

Sustainability

The approach of the Regional Partnership Board statutory partners to sustaining each of the elements of the Stay Well in Your Community Programme has three elements: 1. To conduct ongoing evaluation and refinement of each of the elements of the programme as

soon as they are fully implemented, and to reach conclusions on their degree of success in achieving their objectives and delivering improved value sufficiently ahead of the end of transformation funding, such that a clear view is developed of what elements of the programme will be continued after the end of transformation funding.

2. To develop, test and refine an assessment of the resources which can be released from existing service models as a direct result of the elements of the Programme agreed to be continued after transformation funding ends, and to use this as a partial funding source for the ongoing recurrent annual cost.

3. To develop the value based case for utilising additional Welsh Government for seamless integrated care to meet the residual net recurrent costs of the transformation programme after deducting costs released from existing service models as per (2) above.

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Whole System Model Overview Our locally developed evidence base for population segmentation, proactive risk management and anticipatory care and support, together with a rapid, flexible community response leads to the next phase of our transformation journey being the scale up and further integration of our community based health and social care. We recognise however, that the full benefits will only be realised with delivery of the whole, Cwm Taf wide, transformation programme, including promotion of health and wellbeing, particularly in the first 100 days and acute health and social care redesign.

Tranche 1 of the Stay Well in Your Community Programme aims to scale up existing successful Cwm Taf pilots and develop new services where evidence suggests the region would benefit. The aim is to develop a whole system model linking Multidisciplinary Anticipatory Care and Enhanced Routine Monitoring Services with our Rapid Response Services.

Enabling this work are key workforce and digital strands. These consider health and social care workforce sustainability, designing, in partnership, new workforce roles which are fit for delivering our seamless model of health and social care and digital, data and technology which provides a shared record via Vision 360 and applies supportive artificial intelligence to guide clinical care.

Cwm Taf Social Services and Wellbeing Partnership

Stay Well in Your CommunityThe Service Model

Community Coordination

Rapid Response Services• Assistive technology • Nursing @Home Team• Medicines @Home Team• Equipment• Mental Health Crisis Response Team• Social Care• Therapies• Transport and Settling Services• Third Sector Support Services• Access to step up and step down beds, inc.

transport

• AI symptom Checker

• Advice & Signposting

• Video Consultation• Urgent Primary

Care Centres

Clinical Triage

Urgent Primary

Care Services

Multi Agency & Disciplinary Cluster MDT

Multi Agency & Disciplinary Cluster MDT

Multi Agency & Disciplinary Cluster MDT

Multi Agency & Disciplinary

Practice/ Cluster MDT

Community Carers

Other Community Assets

Enhanced Community Cluster Team (Local Authority, Health & Third Sector)

Which may include:* Anticipatory care *

Non urgent assessments* Short term care and support (max 4-6 weeks) *Local long term care *Advanced care planning / end of life

Proactive chronic conditions management * POCT *Intermediate levels of care Localised advice/ support/

signposting * Liaison with rapid response *Routine monitoring * Multi professional assessments in home, care or residential * Specialist advice assessment and

intervention therapies *Linking and utilising community assets

Risk Score/ Segmentation

Professional

Technology

Public

MultiAgency &

DisciplinarySingle Point of Access (Merthyr & Rhondda Cynon Taff)

Professional and patient line in hours& Professional line only OOH

Proportionate assessment8.30am to 8.00pm

Existing Pathways

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At the point where a member of the public says “I think I have a health or social care problem. I need assessment and possibly ongoing routine support from peers and professionals”, they will make contact with a health, social care or third sector professional either in or out of hours. Alternatively, again both in or out of hours a piece of assistive technology within an individual’s home will either make immediate contact with the Single Point of Access (SPA) or trigger a flag within the Enhanced Community Cluster Team (ECCT) for review at the next MDT meeting. Also, on a regular basis the population health segmentation and risk score information for the Cluster will be reviewed by the ECCT to identify individuals who may benefit from a more holistic assessment or a more targeted health or social care service. The whole system model then delivers through the following example scenarios:

Scenario Current Experience Future Experience

A lives alone and has a lifeline pendent linked to a monitoring centre. A falls and presses the pendent.

The monitoring centre responds and contacts A who says she is unable to move from the floor. The monitoring centre calls Welsh Ambulance Service.

On examination A has no bony injury, however due to A's vulnerability and in the absence of any response services, Welsh Ambulance Service staff feel concerned at leaving A home alone with no support so convey A to A&E.

At A&E SW@H phase 1 assess A as able to return home and discharge with support.

A's lifeline pendent alerts the monitoring centre, the monitoring centre establish A is unable to move from the floor so send the Assistive Technology (AT) response service which aims to respond within 30 minutes.

The AT response service attend A and undertake an initial examination using training provided by the Welsh Ambulance Service and establishes A has no bony injury.

The AT response service use specialist equipment and lift C from the floor and provide some support. The AT service then refer to SW@H Single Point of Access who commission enabling support.

B lives alone, his only daughter C has significant other caring commitments and works part time, resulting in weeks passing where she has no contact with her dad.

Over time B loses confidence and rarely leaves the house. C is unable to offer additional support and worries about her dads deteriorating condition adding to her already stressful situation

C is aware of the marketing campaign for a new Assistive Technology service and contacts the AT service. The AT service undertake an initial assessment of B's situation, provide a lifeline pendent and/or other equipment/technology and a programme of telephone support for B. B is called every 3 days to check on is wellbeing, encourage him to go out and about and link him with activities he enjoys in his community.

The AT service also provides C with periodical updated on B's progress. If B reports he has not left the house for a few days or is feeling unwell the AT service dispatch the response service to attend the person and undertake a wellbeing check on B. This provides an opportunity for other services to be commissioned, including the Enhanced Community Cluster Team, and Third Sector Partners if required before a crisis situation is reached, it further provides support to C as she no longer worries about support for her dad and is able to focus on her own commitments.

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Scenario Current Experience Future Experience

Mr D lives alone with support from his niece. He has a twice a day package of care. He is 90 yrs. old with diabetes supported by the district nurse and suffers with COPD

If Mr D becomes ill, one of his domiciliary care providers or the district nurse contacts the GP and he received a home visit. Treatment is put in pace to manage this acute need.

He is admitted to hospital at least twice a year often because of his COPD. His time in hospital is often long and his discharge is often complex due to reinstating his care and organising his transport etc.

Mr D has been flagged through Risk Stratification by the practice as needing an MDT review by the Enhanced Community Cluster Team.

The most appropriate member of the team goes out to assess and then organises appropriate inputs from OT to support aids that will help at home.

An Anticipatory Care Plan is put in place to support the domiciliary care provider to recognised symptoms and to call the team at an early stage.

When he is deteriorating, the team are called out to provide IV antibiotics at home to prevent his admissions to hospital where ever possible

The team review Mr D on a regular basis and advises the domiciliary care providers and the District Nurse of any changes that would support Mr D staying at home.

The Advanced Care Planning nurse (ACP) agrees to meet with Mr D and his niece to record his wishes about being hospitalised or being cared for at home and to develop and ‘advanced care plan’ in the event of him being very unwell and what his wishes would be.

Mrs E is a 75yr old lady who lives at home with her husband who has dementia. She visits the GP regular as she suffers with Arthritis, COPD and Anxiety. She worries about being able to manage her husband as his dementia gets worse.

Mrs E is offered GP appointments on a regular basis as she requests them.

Her symptoms are generally managed but she continues to attend often with minor issues.

She has been admitted with chest infections in the past where her husband has needed to go into emergency residential placement while she is in hospital, this is distressing for them both

The GP highlights Mr and Mrs E as needing an assessment by the Enhance Community Cluster Team.

A member of the team goes out to do the initial assessment with both Mr and Mrs E. They agree an anticipatory care plan for them as a couple is needed as they are very interdependent on each other.

A plan is agreed with members of the MDT including mental health and a carers assessment is also undertaken for Mrs E. Day centre care for Mr E is agreed 2 days a week to reduce the demand on Mrs E and she is referred to the Community Co-ordinator to link her in with local groups when Mr E is in day centre.

The couple are visited on a regular basis by a member of the team to ensure the plan continues to meet their needs.

Treatment is offered to Mrs E much earlier around her COPD / chest infections to maintain her at home to reduce the possibility of admission for her to hospital and emergency care needs for Mr E.

G hasn’t been eating or drinking as she feels unwell. Neighbour calls GP surgery in-hours or contacts the OOH GP. GP concerned about mobility and

At A & E SW@H phase 1 team assess G, who is discharged home with some simple equipment such as a commode and a package of support from the local authority. G’s GP is notified.

GP contacts the Cwm Taf SW@H Single Point of Access trusted assessor who undertakes a "What Matters" conversation and proportionate assessment with information from the GP, neighbour and or G herself. Services, including Third Sector and/or equipment are commissioned to support G not to attend A & E but to receive appropriate support in the community.

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Scenario Current Experience Future Experience

ability to manage at home and send to hospital via A & E.

The Enhanced Community Cluster Team are notified in order to provide short term care and support.

Mr H is currently being supported by his wife with daily activities such as feeding, washing and dressing due to degenerative condition. District nurses call regularly. Mrs H is struggling and feeling unwell herself but does not confide in anyone as she is worried what will happen to Mr H. If she is not able to continue to support him. Saturday morning on a routine visit the district nurse calls to find Mrs H unable to manage and Mr H has not eaten or washed or dressed.

The District nurse calls out of hours GP who in the absence of any additional support to be provided at home admits both Mr and Mrs H to hospital.

District nurse calls GP out of Hours and the SW@H Single Point of Access, both Mr and Mrs H are provided with a package of support from the local authority Support @home/Initial Response the Enhanced Community Cluster Team are notified in order to follow up appropriately.

Mrs I has been in hospital with a suspected UTI for 4 days. She didn’t really want to come home, but was discharged on Friday. Mrs I lives alone but receives some support from her children however her main carer is on holiday. Her daughter called OOH on Saturday seeking readmission or some other placement option for her mum. The daughter reported that the patient had not been coping at home for months, issues of loneliness and isolation, feeling hopeless, didn’t want to be here, reported to be getting confused re tablet administration and saying might as well just take them all. The Primary Care OOH team agree with Mrs I’s daughter that this was not solely an acute medical problem.

Following a discussion with Primary Care OOHs Mrs I’s daughter spoke to the @home team – who were very understanding but couldn’t help as they have no social care resources. Following a conversation with the social services duty team a unable to arrange placement or urgent care package over the weekend wasn’t possible to arrange over the weekend. Mrs I’s daughter rang Primary Care OOHs again where the option of carrying on at home with family support was discussed but wasn’t felt tenable by the family. As a consequence Mrs I was sent into hospital again via ambulance.

Following a discussion with the Primary Care OOH clinical triage team, the team contact the SW@H Single Point of Access. A "What Matters" conversation and proportionate assessment is undertaken and Services, including Third Sector and/or equipment are commissioned to support Mrs I. The Enhanced Community Cluster Team are notified in order to provide short term care and support. Mrs I is not readmitted to hospital.

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Programme Governance and Delivery The Stay Well in Your Community Programme will be governed through Regional Partnership Board reporting structures. A Partnership Programme Management Office will be established to enable delivery of the Programme, with addition external support commissioned to facilitate development of an in-house evaluation function. The Programme will be managed via a monthly Stay Well in Your Community Programme Group. This Group will align closely with the Area Plan Development and Implementation Group to ensure the opportunities provided by the delivery of the Area Plan are maximised.

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Workstream 1 – Risk Stratification and Segmentation

Evidence Base

The need for healthcare varies within populations with a small proportion of people needing the greatest amount of resources. It is common for people to have multiple chronic conditions. This multi-morbidity is not evenly distributed across the population with case mix varying across GP practices and clusters. This impacts on resources and costs in an exponential, not linear, way. It is a key driver of healthcare use and future risk, even more so than age, and occurs across the whole of the adult population, not just the elderly. Understanding patient populations, groups or clusters by characteristics related to their need and use of health care resources can help Primary Care Clusters and GP Practices to decide how best to use limited time and resources to deliver anticipatory and pre-emptive care for patients. The Rhondda Cluster Risk Stratification and Segmentation Pilot - see page 1. Work commissioned

by the Health Board to understand the population profile of the Rhondda Cluster practices led to the

following insights:

The cost profile within the pilot population - 1% of patients account for 19% of costs across the pilot health board area. However this cohort of patients may not be amenable to standard interventions.

The morbidity burden across the geography - Multimorbidity is the norm – it is more common for people to have multiple chronic conditions than to have just one.

Interventions should not focus on one condition but take into account groups of conditions which can co-occur

The relationship between frailty and multimorbidity - Multimorbidity rather than age or frailty is the key driver of cost.

How casemix can be used to account for morbidity when performing comparisons - Casemix adjustment can be used to allow a true comparison of providers or areas.

The overlap between different risk models - Ensure the right risk model is used when identifying patients for an intervention. Not doing so can limit the effectiveness of the intervention and put patients at clinical risk.

There is significant variation of need across the pilot population.

Scope and Model

Population Segmentation supports population-based service planning and refers to the use of ‘big data’ to divide populations into distinct groups based on their collective characteristics, for which intervention programmes can be designed. The tailoring of interventions to specific segments is considered the best way of ensuring the most effective use of healthcare resources.

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Risk Stratification will be used to calculate individual patient risk scores using a range of modifiable and non-modifiable factors. Example risk models which will be applied to the ‘big data’ are:

Probability Emergency Hospitalisation

Probability Inpatient Hospitalisation

Predicted Relative Cost Weight

Predicted Relative Pharmacy Cost Weight

Mortality Risk Score

These scores can be used at a GP practice, GP cluster and Health Board level to identify individuals

or groups of patients within the highest risk groups and to enable the management and reduction of

risk through targeted and anticipatory care.

Building on the successful Rhondda Cluster Pilot it is proposed to commission a key partner organisation to carry out a range of predictive algorithms which includes the ACG model and others. For the risk models to work with the greatest accuracy and reliability, a minimum of 70,000 patients is required. This is achieved by working with whole primary care clusters. Detailed planning and strict adherence to Information Governance procedures is required to secure approval of the data extraction. All parties are required to signed a Data Disclosure Agreement. Data Quality Systems and Data Extraction Specification documentation has also been developed, to ensure that the data is accessed safely and used appropriately for its specified purpose.

Overview of the Population Segmentation and Risk Stratification Model

1. Patient Data Extraction

2. Population Segmentation and Risk Stratification

3. Data Analysis and Interpretation

4. Identification of Evidence-Based

Interventions

5. Anticipatory and preventative care

6. Measureable Long Term Outcomes

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Key Deliverables

A description of each stage of the Population Segmentation and Risk Stratification Process.

1. Patient Data Extraction

Primary care patient data held by the NWIS will be extracted and linked to secondary care data using patient’s unique NHS number. This information will be passed securely through the NHS Wales networks to a key partner organisation. The extraction will include a range of fields including healthcare resource use, health conditions, personal and lifestyle factors.

2. Population Segmentation & Risk Stratification

The key partner organisation will apply the Adjusted Clinical Groups population segmentation and risk stratification model, among others (see Appendices), to the data. By combining information on a range of acute and chronic conditions and healthcare usage, it is possible to identify groups of patients based on their holistic need, rather than just disease condition. Once the process is complete, the data will be available through an online portal. Users of the data will be allocated appropriate access to ensure that patient data confidentiality is maintained.

Health Board and Public Health Wales Users – This data will be anonymised, aggregated, population-level data which can be used for service redesign, commissioning, investment and strategic decision-making.

Cluster Users – This data will be anonymised, sub-population and patient-level access to facilitate Cluster service redesign and planning and resource management.

GP Users – GPs will have access to patient-level information, providing the opportunity to target interventions at individual patients from within their practice area who have the highest risk scores.

3. Data Analyses & Interpretation

Once the online platform is made available to the users, the data will undergo detailed analysis by the Public Health Team to identify target populations and patient cohorts with the greatest level of need. Assistance and training will be offered to clusters and GP practices to enable them to interpret, tailor and use the information independently for purposes such as identifying practice-specific priority patient groups, regular reporting, auditing and benchmarking.

4. Identification of Evidence-Based Interventions

The Cwm Taf Public Health Wales Team and GP Clusters will work collaboratively to identify priority areas for targeted intervention. A range of evidence-based interventions will be identified which best fit the population need. The evidence-base will support the development of existing services and, if appropriate, will support investment in new models of care.

5. Anticipatory and Preventative Care

New and re-modelled interventions will be implemented to support population health improvements and reduce risk.

6. Measureable Long Term Outcomes

Subsequent data extractions will be carried out at regular intervals to enable effective monitoring and evaluation of the impact of any new interventions. This will highlight any changes from the baseline to indicate the level of success an intervention has had on its target patient group. The effective management of population health should reduce demand for unscheduled, primary and secondary care and help to ease the pressure on appointments. It should also help to prevent unplanned emergency admissions to secondary care and keep people healthy and at home for longer.

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Delivery Plan

Overview of Population Segmentation and Risk Stratification

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Year 1

Procure

Recruit* Agree Data extraction & segmentation Analysis of Findings

Establish Extraction and data transfer

Refine model Risk stratify using ACG

Analyse segments

Scope

Key Partner Organisation

Information governance

and data spec

Collaborations

Other data sources

Year 2

Establish Outcomes, review the evidence and carry out a gap analysis Imbed new models of care

Stakeholder engagement

Agree outcomes

Systematic Review

Year 3

Ongoing segmentation, risk stratification & quality improvement cycles

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Workstream 2 – Assistive Technology

Evidence Base

The Barcelona Model is upheld as a 'best practise' model, as it incorporates key elements such as proactive monitoring as well as a response service. However, there are local examples of AT models that have also assisted the development of the model - in particular Cardiff CC and Bridgend CBC who both have mobile response services that have helped to reduce demand on emergency services through responding to fallers. In the Barcelona region, the AT service is provided by Tunstall Televida, who support 67,000 service users with Barcelona's municipal teleassistance service (SLT). The service combines telecare monitoring and response, coordinates social care and third party services and delivers proactive outbound contact from monitoring centres. Teleassistance aims to provide continued contact/support to older and vulnerable people in the community, helping them to remain independent for as long as possible and delay or avoid the need for more complex interventions. Currently 10% of people over 65 and 25% of people of the age of 80 are in receipt of the SLT service. The model is based on a tiered system of needs based intervention and is predicated upon prevention as well as reaction, the model includes an upfront assessment, appropriate technology installation, proactive outbound calling and the deployment of a mobile response unit.

Barcelona Proactive Outbound Calling Model

Tunstall Televida employs approximately 260 staff, with around 35% working in the monitoring centre, and half are home care personnel, such as mobile response officers, social workers and technicians/installers. The key features of the Barcelona Model are outlined in the table below:

Assessment 200 piece assessment to determine which AT should be provided/requirement for proactive reassurance calls

Monitoring Centre

answer incoming calls in less than 10 seconds

60% of calls are outbound proactive calls

Mobile Response Unit

11 mobile response units

24 hour response to emergencies, swift response to fallers or social care emergencies

Must reach a call with 30 minutes

Reviews of the Barcelona service report:

The inclusion of the preventative element in the model has been a key to its success, it has reduced the number of emergency service escalations, improved the wellbeing of users and made effective use of public services.

Reduced emergency calls from end users and their families which has correspondingly reduced ambulance call outs and A&E attendances.

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For every € that is spent, €2.5 is saved. This is based upon cost avoidance reporting.

Scope and Model

An Assistive Technology Service is currently operational in Rhondda Cynon Taf and Merthyr Tydfil. The service offers a lifeline unit, and where appropriate other more specialist equipment such as fall detectors linked to a monitoring centre. The monitoring centre responds to the activation of the pendent/ specialist equipment. Currently the monitoring centre would call family member/carer or the emergency services to respond to the lifeline activations. The new model continues to provide the range of lifeline equipment with an additional offer of proactive outbound telephone calls at regular intervals to check on and support an individual's wellbeing. In addition the new model will provide a 24 hour mobile response service which will aim to respond within 30 minutes to 1 hour. The service will operate 24 hours a day, 365 days a year responding to all triggered alarms and establishing/deploying the most appropriate response. The initial assessment will identify the need and frequency for proactive or reassurance calls via a wellbeing plan. The monitoring centre will undertake the telephone calls which could include daily, weekly, fortnightly or monthly contact. Where a proactive/reassurance call identifies that an individual's needs have changed or a reported 'dip' in that individual, the monitoring centre can deploy the response service. The proactive element will also be utilised to promote any particular Public Health wellbeing promotions or to share important announcements that could potentially benefit individuals in receipt of the service, e.g. maintaining hydration in the warm weather. Following the initial assessment suitable equipment will be provided and installed and the programme of well being support commences and will be reviewed annually. In circumstances where activations trigger an earlier review this will be undertaken and the well being plan adjusted. The individual will be pro actively called to provide support to maintain wellbeing, provide reassurance and deliver public health messages. The proactive outbound calls will provide carers support and peace of mind while supporting the individual to remain well and continue to live independently in their own home. The mobile response service will provide a response to lifeline unit alerts, deliver well being calls in response to concerns raised from the outbound calling system and periodically carry out tests on the equipment to ensure it remains in good working order. The new service will provide an additional offer for community professionals and the public. The model provides clear and robust pathways for AT, ensuring that individuals who require technology enabled care receive the 'right' offer tailored to their needs. The model supports the wider Stay Well in your Community transformational programme and links specifically to the risk stratification work, and the preventative service development.

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Development of this model is based upon best practise from research of other models, incorporating an improved offer to service users around 'new' technology along with a response service that is aimed at supporting individuals at home, supporting carers and preventing unnecessary calls to Welsh Ambulance Service and attendance at A & E.

Key Deliverables

Innovative proactive, preventative model of support

Underpins the preventative agenda of the transformational model for Cwm Taf linking with other service developments in the transformational programme

Direct referrals and pathway for community professionals

24 hour, 365 day response service

Provides an alternative to calling Welsh Ambulance service for non-urgent cases

Provides an alternative to A & E attendances

Regular checks on wellbeing to prevent deterioration in individual circumstances

Reduce unnecessary demand on Welsh Ambulance service and reduce conveyances to A&E

Links with third sector and community well-being services

Ensures appropriate levels of service provision Outcomes

Workstream Contribution to the Cwm Taf Whole System Outcomes Framework Local Workstream Outcomes

Promotes individual well being

Supports families and carers

Individuals are supported to remain safely within their own home

Provides reassurance, updates and support to carers

Provides reassurance and updates to community professionals

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Delivery Plan

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Workstream 3 – Enhance Community Cluster Team

Evidence Base

One practice within the Cwm Taf 'St John's medical practice in the Cynon Valley' area has over the last year been developing a ‘Virtual Ward’ multi-disciplinary approach to address the needs of their patient’s population. See page 1.

The primary-care based model aims to deliver an MDT approach to the top 3% of service users within a practice.

The current model is managing around 240 patients per year at St John’s which is hitting the 3% target.

There is a dedicated MDT meeting on one day a week to design and implement care plans, and then delivery takes place over the rest of the 4 days of the week from the team and the GP practice.

Following an audit of 150 patients a year before the new model and then after the new model was introduced showed the following key outcomes:

GP OOH’s 91% Reduction in contacts

GP in Hours 57% Reduction in contacts

Hospital Unscheduled Care 76% Reduction in activity

Estimated costs and saving form within the St John's model have been explored and are felt to be a valid basis for our future work. We believe that if we expand this model further and embrace more actively our local authority and third sector partners this work will transform the way we work. This work has seen very significant success and forms the core basis of the Enhanced Community Cluster Team (ECCT) model. Scope and Model Clusters will take on a strategic role and will directly plan, organise and manage services for their local populations. They will be responsible for the coordination of seamless holistic health and social care services and teams organised around the individual and the family as close to home as possible. To do this Clusters will need to organise themselves in such a way as to be able to work with the Health Board, Local Authorities and Third Sector agencies. Anticipatory Care - Anticipatory care involves case identification and proactive intervention to reduce hospitalisation and mortality rates. We intend to use population segmentation and risk stratification to improve patient care in Cwm Taf. This will move from a system of reactive interventions to one of anticipatory care which proactively manages escalation of need through seamless working. Understanding patient populations, groups or clusters by characteristics related to their need and use of health care resources can help Primary Care Clusters, GP Practices and Local Authority to decide how best to use limited time and resources to deliver anticipatory and pre-emptive care for patients. The necessary interventions will be made by the appropriate member(s) of the holistic multidisciplinary team or Enhanced Community Cluster Team. Learning Environments - The multidisciplinary/multi-agency model will provide a continuous learning environment for both the individual and the system. This will be supported by the Pacesetter initiative to develop Advanced Training Practices which provide multi-professional and multiagency training environments to ensure we develop a skill and flexible workforce, able to work across boundaries.

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The ECCT - Based on the experience of the Cynon pilot, we expect the Team to consist of any number of the following workforce:

GP Staff i.e. GP's, practice nurses etc

Clinical Pharmacists

OT, Physio, Podiatry, SLT, Dietetics

Community Paramedics

Advanced Care Planning Nurses and palliative care inputs

District Nurses (Neighbourhood Nursing Teams based on Burrtzorg model)

@Home and Stay Well @Home staff

Physicians assistants

Current Chronic Disease Specialist Nurses based in the community and then reach into acute care

Hybrid workers to support Chronic disease management

Health Visitors

Social Care Staff

Domiciliary Care staff

Care of the Elderly medical inputs

Welsh Ambulance Service or alternative provider

Swift access to secondary care / specialists for advice and support

Diagnostic Staff with localised access

Third Sector workers especially community co-ordinators / social prescribing

Community midwives

Inputs from paediatric community consultants and CAMHS

Management and administration support Many of these staff already exist but do not work in this way and are not aligned or managed through a single integrated process / team. We would expect those outlined above to be brought together under one team for each of the clusters. It is clear that we will need different amounts of resource from each professional group dependant on need. Some of this will be moving existing services into the team and other elements will be additional staff from within those groups to take on this new model of care. To truly obtain the best outcome for each Cluster, local engagement and co-production will be undertaken to shape and refine both the makeup of the Cluster MDT and how it links and grows community assets and social prescribing pathways. With a stratified patient list, managed through an MDT process we believe that we can provide a proactive anticipatory approach in a scheduled way to all citizens / patients that currently are predominantly managed reactively. We will maintain our vulnerable citizens within their home of residence where ever that might be supporting proactively our residential and nursing homes ensuring that we avoid unnecessary admissions. A key component will be the support for 'advance care planning' to ensure all professional understand the citizens wishes. This will reduce the unscheduled activity and allow for more planned and anticipatory offer Example Operating Model – see diagram overleaf The operating hours of the system will be defined by the service components, with referrals being accepted in the first instance 9-5pm Monday to Friday which is aligned to our other intermediate care services for example, SW@H.. The initial proactive approach is for the population to be stratified by using a stratification tool. This will segment the population into categories for example: No intervention, Annual Health Check / Support and Advice, Routine anticipatory support / care plan to be put in place (low level / moderate level), High level wrap around care plan to be put in place. This work is all planned and will be carried out by the members of the ECCT and potentially others. Feedback will be through the MDT meetings as noted below. Any health / social care / other workers will be able to refer into the ECCT with the patient / families consent. This will then be manged through a triage process at a cluster / GP level. This will be defined on a cluster by cluster basis. The response will then be determined by the triage GP/Team

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Enhanced Community Cluster Team Model

Population Stratified / Segmented Clustering individuals within the practice population based on identified characteristics and on their healthcare use

profiles will identify new segments of the population with similar needs. Their future risk and health and social care usage will then be predicted and interventions and multidisciplinary/agency teams will be targeted at those

groups.

Anticipatory care A multidisciplinary assessment to

produce an anticipatory care plan for the individual and their family; inputs

include access to the ECCT/@home/social services/mental

health & psychological support; remote monitoring; end of life care including advanced care planning; Rescue medication packs / plan for

WAST

Localised Advice/ Support Signposting to common

ailments, WHECS, all third sector support and all primary

care contractors; local authority support i.e. housing and

benefits; community teams (health visiting etc.)

Routine Monitoring At home or in clinic with

member of ECCT and wider community; telecare and

telehealth; POCT; local diagnostics; regular

assessments within care and residential homes; liaison with

rapid response and anticipatory care

Rapid Response Service Maintain at home – IV Antibiotics,

Domiciliary Care, Remote Monitoring, Step up care in community hospital, urgent assessment by GP / physician

associate /ANP/ Paramedic; support and advice from specialist mental health and

paediatric teams; assessment and interventions by therapies; specialist

support from COTE and @home; WAST pathways (COPD, Diabetes, falls); local

diagnostics

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and a response will be agreed as shown in the diagram below. A response tool will be used to determine the urgent nature, Red / Amber / Green calls (as in the @home service) and a timescale will be agreed for the response. The ECCT team will link in with the @home team and the Stay Well @home team ensuring an integrated service offer. An MDT process for discussing cases on a weekly basis will be put in place as will urgent access to professional advice and support. Key Deliverables

Deliver multi-agency, multi-disciplinary working at cluster level

Delivering care closer to home by facilitating access to services within the cluster

Links with third sector and community well-being services

Accelerated cluster development and operationalised cluster governance

Improved GMS sustainability

Better use of skills and resources across the whole system

Shared information systems across seamless system to enable seamless care

Development of a range of new extended roles- adding skills competencies and experience to the Enhanced Community Cluster Teams.

Outcomes

Workstream Contribution to the Cwm Taf Whole System Outcomes Framework Local Workstream Outcomes

The shift of interventions from clinical environments to an individual’s home environment where ever that may be

Improved access to primary care services, i.e. reduced waiting times and patient satisfaction

Increased levels of planned care and decreased levels of unscheduled care

Increase in the number of people with an anticipatory care plan

Improved patient outcomes (based on defined clinical need)

A reduction in acute outpatient appointments

A reduction in medicines management costs

Demand reduction for out of hours services

A reduction in the impact of seasonal variation with the services proactively supporting winter pressures

Reduction in ambulance hospital conveyances and the length of stay of acute care of admissions

Improvement in patient safety

Improved infrastructure and utilisation of IT and AI across Health and Social Care

Increased Advanced Care Plans within individual homes of residence

Increase the levels of mentorship / training and development to team members

Reduced waiting times to diagnostic and increased access to Point of Care Testing

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Delivery Plan

22

Workstream 4 – Stay Well@Home Single Point of Access

Evidence Base

Stay Well@Home phase 1 - see page 1

Scope and Model

The SW@H phase 2 model builds on the success of phase 1 which focused on developing a service, accessed from A&E, which avoided unnecessary hospital admissions and supported timely discharges from hospital to home. Phase 2 focuses on the step before the hospital, providing support to citizens in their own home to avoid the need to attend hospital. This will be achieved by developing one Single Point of Access for Cwm Taf for all referrals for community professionals (both health, social care and third sector) 365 days a year from 8.00a.m. to 8.00p.m. Community professionals such as GP's, GP out of hours, Welsh Ambulance service, district nurses, social care and third sector professionals will be provided with one telephone number for the Cwm Taf Single Point of Access. A trusted assessor based at the Single Point of Access will then discuss the presenting need with the community professional and the citizen themselves using the "What Matters" conversation in line with the Social Services and Wellbeing Act, along with a proportionate assessment. Appropriate community services will be commissioned in response to the citizen's individual need via the existing community coordinators. The model will provide community Occupational Therapists to support any mobility or moving and handling concerns, supported by the provision of the community equipment service both in and outside of core hours.

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The range of community services aiming to respond within 4 hours include:

Support @home and Initial Response Social Care Enabling Support Services

@home Community Nurses

Simple and specialist equipment (includes commodes, key safes, hoists etc)

Step up /down beds

Community transport

These services will be supported by community pharmacy, where review of medication is required, this service will operate in core hours only. Key Deliverables

One Single Point of Access for Cwm Taf with one telephone number for community professionals to contact 365 days per year from 8.00.a.m. to 8.00p.m.

Trusted assessors providing a what matters conversation and proportionate assessment to enable the appropriate response to be commissioned for the citizen.

A range of community services (Support @home, Initial Response, Nursing @home and community equipment) aiming to provide a response within 4 hours

Community Occupational Therapists to assess and respond to mobility and moving and handling concerns

Community equipment service able to deliver simple and more complex equipment including the fitting of key safes, and the moving of furniture where required.

@home nurses able to support the citizen e.g. IV antibiotics.

Access to community Step/up down beds

Access to community transport in and outside of core hours

Access to community pharmacy for medication administration assessments and support

Single telephone number for community professions 365 days per year

A clear pathway across Cwm Taf

An alternative to sending or conveying citizens to A & E departments

Community services available 365 days per year outside of core hours Outcomes

Workstream Contribution to the Cwm Taf Whole System Outcomes Framework Local Workstream Outcomes

Seamless service offered to the citizen from a regional approach to service delivery

Provides an alternative offer to attendance at A & E depts. or admission to hospital.

Improved response times as accessing the right service

Citizens experience good quality care

One health and social care system

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Delivery Plan

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Workstream 5 – Urgent Primary Care Out of Hours

Evidence Base

There is a Strategic Programme for Primary Care and the core component of this is the implementation of a Primary Care Model for Wales’ and which aligns well with ‘A Healthier Wales’. Cwm Taf Health Board is aiming to implement this model not just in hours but also to Urgent Primary Care (OOH). This work stream and resource forms just one small element of the wider transformational change programme for Primary Care. Key components of this model are:

Informed public

Empowered citizens

Support for self care

Community services

First point of contact

Urgent care

Direct access

People with complex care needs

MDT working Critical to the success of the model is the need to work across organisational boundaries 24/7 in order to maximise all the services and assets across Cwm Taf. Cwm Taf OOHs service is at present almost solely dependent on GPs to undertake clinical phone triage as well as face to face contact both in Primary Care Centres (PCCs) and for Home Visits and that this dependency is a major cause of the system vulnerability. This model is now out of step compared to many other parts of Wales and compared to the Primary Care Model. The development of the Multi-Disciplinary Team is being implemented across Wales in other OOH services and within 111 and is having a positive impact on patient pathways and managing demand more appropriately but also and more importantly it is having a positive impact on patient experience. New roles within OOHs will include ANPs, District Nurses, Advanced Care Planning Nurses, Paediatric Specialist Nurses, Mental Health, Paramedics and MSK Physios. It is believed that in time (within 18 months) these specialists will be able to reduce in the first instance 25 – 30% of the patients from the GPs workload. Work is progressing on the development of these pathways and roles but the immediate need is to appoint a Clinical Nurse Lead and nurses who will be able to work alongside the GPs to triage but also to see and treat. A Healthier Wales’ and the Primary Care Model points us towards exploring digital solutions, which is not an area previously explored in depth from a primary and community care perspective. Based on “pilots” undertaken through NHS Digital and in reviewing international evidence, the use of applications and web-based programs have been estimated to reduce demand from patients (circa 35%) from the system encouraging self-care and providing advice to the user on the more appropriate sources of support; including Pharmacists, Optometry and Dental services. The ambition is to deploy in due course an app with AI and machine learning within the next two years. For those that do require more immediate help (65%), it is considered that having the full patient’s details earlier on in the process and an initial basic screening of the patient will enable better management of the Triage Queue during the shift in terms of Face to Face appointments and Home Visiting. In terms of demand it is estimated that the use of an app will reduce the net number of patients entering the Triage Queue by circa 2000 per annum in the very first instance.

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This aspirational new model was presented as part of the OOH Peer Review and was tested out by the Peer Review team. The Peer Review team were pleased by the overall direction and strategic vison for the service and how we are aligning this with NHS Wales 111 to ensure the model delivers a safe and effective service. The team considered that it was congruent with NHS Wales 111 services and in line with national policy.

Scope and Model

The new aspirational model is focused on:

maximising the opportunities from the application of artificial intelligence to sign post patients to self-care and appropriate alternative services

the strengthening the MDT team triaging through the 111 clinical services hub and and will aim to support and boost the current GP workforce in terms of triage, face to face appointments at Primary Care Centres and Home visiting.

The pilot of digital AI technology will provide an opportunity for the Health Board to test the impact of technology such as symptom checking app and Video assisted triage. The video assisted triage would provide an option to augment traditional telephone triage by visualising a patient’s general condition from the ‘end of the bed’ – an invaluable tool used by and immediately understood by clinicians in daily F2F consulting. In addition, it could be used for specific visualisation of a skin condition which would not otherwise require F2F assessment in base or home visit. The service will be enhanced via Community Nurses and paramedics who will increasingly be the ‘eyes and ears’ of an OOH clinical team stretched at times of peak demand to meet the needs of an increasing house bound population. Many presentations that currently are dealt with by home visit could be dealt with using video assisted triage. The wider role out of Independent Prescribing within our community teams would be advantageous here too. The technology required is user friendly relatively and operable at low specification, functioning on almost all smart phones and tablet computers using a 3G or WIFI connection.

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It is proposed once fully implemented Video assisted triage could support our community nurse teams, care homes and paramedics as well as providing triage or online consulting direct to patients. Key Deliverables

Providing patients with alternative advice and signposting via the use of digital technology, e.g. symptom checker and advice.

Strengthening the clinical leadership to help teams with decision making

Strengthening of nurse triage (telephone and face to face) to increase capacity

Development of a wider Multidisciplinary team, including paramedics, advanced care planning nurses, mental health

Streamlined and seamless pathways to other specialist services which are provided, such Stay Well@Home, end of life care, paediatrics and mental health and respiratory

Streamlined and seamless pathways to non-health services, e.g. social care

Embedding the integrated directory of service into the service Outcomes

Workstream Contribution to the Cwm Taf Whole System Outcomes Framework Local Workstream Outcomes

Reduction in demand as patients will have the opportunity to explore advice via an app instead of face to face with a GP (where it is appropriate)

Quicker access to advice, assessment and therefore treatment

Stronger Relationships with partner services and other health professionals

Improved access to timely advice and treatment for patients requiring with a health need

Positive experience for patients

Improved advice and signposting for patients who do not necessarily need health care professional, e.g. pharmacy common ailments scheme and Optometry

More sustainable Urgent Primary Care Service

Delivery of seamless services for the patient

Better patient experience requiring urgent care out of hours

Reduction in the number of patients having to be referred into A&E

Matching capacity at peak times in order to ensure the service is responsive

x

• People are supported to choose healthy behaviours in ways to meet their needs

• People understand the information, advice and assistance available to them

Outcomes and Indicators.

• People are independent and at home

• People receive targeted care and support (following

population health segmentation)

• People are involved and empowered in designing their care and support

• Flexible, innovative integrated workforce roles are available

• Multi-disciplinary / Multi-agency learning environments are established

• Technology supports: a persons independence, assessment and triage, and communication

• Peoples needs are supported by the correctly skilled professional

• Accessible local services with increased appropriate utilisation

• % of adults who report they have a limiting health problem or disability

• % of adults with 2 or more long term conditions

• Number of people feeling lonely

• Mental wellbeing among adults

• Total time spent at home

• Number / rate of emergency hospital admissions for basket of 8 long term conditions

• People reporting they felt involved in decisions about their care and support

• Number of new roles appointed too

• Number of appointed integrated staff

• Overall staff engagement score

• Staff retention

• % DNA rates

• % of adults reporting they can do what matters to them

• Number of out of hours contacts for people known to be frail

Wo

rkstr

eam

Im

pact.

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Delivery Plan

29

Budget

.

18/19 19/20 20/21

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Recurren

t

Non-

recurren

t

TotalRecurren

t

Non-

recurren

t

TotalRecurren

t

Non-

recurren

t

Total

Multidisciplinary anticipatory care

1 Population segmentation and risk stratification 100 399 399 20 20 200 200 400 200 200

2 Assistive technology at home 260 2,000 2,000 - 1,150 1,150 2,000 2,000

3 Enhanced community cluster team (ECCT) 811 6,053 5,830 203 203 3,351 223 3,574 5,830 5,830

Total 1,271 8,652 8,429 - 223 223 4,701 423 5,124 8,030 - 8,030

Rapid response

4 Stay Well at Home 2 - Single point of access 433 2,200 2,200 - 1,266 1,266 2,200 2,200

5 Urgent primary care out of hours 60 515 515 - 515 515 515 515

Total 493 2,715 2,715 - - - 1,266 515 1,781 2,200 515 2,715

Gold thread enablers

6Partnership transformation programme

management office and programme evaluation 118 493 375 100 100 493 493 493 493

Grand Total 1,882 11,860 11,519 - 323 323 5,967 1,431 7,398 10,230 1,008 11,238

Transformation fund 1,882 11,860 9,978 323 323 5,967 1,431 7,398 10,230 1,008 11,238

Total funding requirement 23,720 18,959

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