Mainstreaming the Carmarthenshire approach to Chronic Conditions Management across Hywel Dda

1. Mainstreaming the Carmarthenshire approach to Chronic Conditions Management across Hywel Dda Kathryn Davies Director - Therapies and Health Science

2. Key Features • Designed to deliver services to meet citizens’ needs and support self management, prevention and early diagnosis • Joint health and social care locality management and service structure • Led by co-located community clinicians and social care practitioners • Single entry point • Shared information with service user permissions • Performance management framework

3. Principles • Risk stratification – to proactively target service users at risk across all 4 levels • Supporting people to self manage wherever possible • Providing appropriate services that meet citizens’ needs closer to their home setting • Developing the workforce and tools to ‘push’ and ‘pull’ service users along pathways • Designing care pathways across the continuum of service delivery irrespective of care setting

4. Outline of geographical localities

5. Translating the CCM model & framework into action • Integrated Locality Leadership Groups – included in Carmarthenshire County Organisational Structure consultation document: • GP • Social Services Area Manager • Community Nursing lead • Care Services Planning Co-ordinator • Core CCM Team / Community Resource Teams co-locating the following staff: • Social Work • Enablement • Domiciliary Care • Chronic Disease Management • Occupational Therapy • Physiotherapy • Disability • Named network links and hot desk facilities for: • District Nurses • GPs • Public Health Wales • Continuing Care Team • Housing Officers • Consultants • Acute Response • Multi-disciplinary team working for clients with complex needs

6. Partnership working and service improvements Partners Service Users Local Authority Health Board NHS Direct Wales Public Health Wales Third Sector Communities First NLIAH, GP Practices CRT Discharge Transport Information Sharing Communications Hub COPD pathway, Generic Support Worker

7. Outcomes for Patients • Ease of access – one telephone number • Whole person / holistic approach • Effective triage / allocation system linking to priority of client • Reduction in routine information giving • Access to a nominated ‘key worker/care co-ordinator’ • MDT for people with complex needs • Development of services within communities in response to needs • Continuity of care • Improved support for informal carers • Specialist services more accessible in the community • Care closer to home • Greater community cohesion

8. Benefits for Staff and Organisations • Streamlined workflow • Improved Information sharing • Reduction in duplication • Integrated health and social services management structure • No ‘dumping’ policy • Services provided on the basis of need rather than meeting ‘criteria’ • Opportunistic dialogue • Better knowledge of what’s available and therefore better advice offered • Better inter-professional working = • Informal training & increased knowledge • Better shared workload • Opportunity to make a difference • Less onward referral – professional ownership • Better informed staff - creation of ‘whole team education & training opportunities’ • Team ownership • Opportunity to develop UAP & joint systems