On a yearly basis, there are 200+ preschool children (under 5) across the health board who need an assessment to determine whether they are on the Autistic Spectrum.

Due to the impact of social communication needs and neurodevelopmental conditions, including Autism, early diagnosis for these children is crucial as it often gives access to specialist services and support for the families. It is well documented that children and people with Autism face inequalities. More recently, the Left Stranded report (2020, National Autistic Society) has highlighted this.

A diagnosis is important to determine a child’s ongoing Additional Learning Needs (ALN) to guide school staff to their provision under the ALN Reform (commencing September 2021).

Receiving a diagnosis of Autism can open many doors for a family and child to receive much needed support and early intervention.

In 2020, there was a disruption in services and the gold standard assessment that we usually utilize, the Autism Diagnostic Observation Schedule (ADOS), is not standardised with the social partner wearing a mask and so could not be used.

We utilized a novel, shorter assessment tool specially devised for use during the Covid-19 pandemic. This required parent coaching, thereby empowering them to be the social partner, rather than the professional and allowing them to carry out the interaction mask free.

This is called the Brief Observation of the Symptoms of Autism – (BOSA) developed by the UCLA based on the Autism Diagnostic Observation Schedule. For more information and the training video click here.

These sessions were carried out by a Paediatrician and Specialist Speech and Language Therapist.

The team of people who carry out the early years neurodevelopment assessments consists of Paediatricians and Speech and Language Therapists.

Project Aims:

To continue the flow of Autism assessments in the Early Years population during the Covid-19 pandemic, by implementing a prudent pathway, moving telehealth to the forefront and increasing parent participation and co-production.

To provide timely, valid and quality Autism assessments in line with best practice and national guidelines, within the context of the global pandemic.

To make long-term improvements to the service by:

• Reviewing the assessment pathway, following the pilot and making revisions based on our findings and to support the reduction of wait times from referral to diagnosis.

• To enhance the families’ overall experience of the assessment pathway by analysing parental feedback from digital questionnaires.

• To identify risk factors and markers that would help us predict which children require a face-to-face appointment based on language skills, neurodevelopmental features and gender, in line with the existing evidence base in relation to telehealth autism assessments.

• This will help us personalise the child and family’s assessment journey.

Challenges:

Key Outcomes:

From September 2020 to March 2021:

We were able to reach a diagnostic outcome for 85 children. Of those 74 received a diagnosis of autism. Without our new approaches, these children would have remained on the waiting list.

The new clinic assessment allowed us to conclude outcomes for 62 children.

• 51 children were given diagnosis of Autism
• 9 children were given the feedback that their primary needs were language disorder or global developmental delay
• 2 assessments were incomplete

Parent Experience:

Social Communication telehealth feedback

85% of parents who completed the questionnaire ‘strongly agreed’ or ‘agreed’ that their child’s communication and interaction needs, difficulties and strengths were understood by the Speech and Language Therapist.

All of them, with the exception of one, said that they would recommend the session to those with similar needs.

Face-to-face clinic assessment feedback:

95% of parents who completed the questionnaire agreed with their child’s diagnostic outcome.

Next Steps:

Going forward we want to explore the clinical markers to decide which children are likely to need face-to-face assessment and which ones can be offered telehealth in the first instance. For example, we have found that in this pilot project, that those children with sentence language level with a mixed presentation have needed a face-to-face assessment.

When we asked parents who had received both clinic and telehealth appointments where they would like their child seen in the future. Their choices were as follows:

• 14 said Mixture of both
• 20 said Clinic appointment (based on new assessment)
• 2 said Video call appointment from home

It would be beneficial to revisit this feedback with a larger group. Going forward, we would envisage carrying out a mixture of both telehealth and clinic to support patient choice, balanced with our capacity to reduce the waiting times overall.

There are possible opportunities to undertake a research project in collaboration with Swansea University.

We also have plans to strengthen our support and intervention for children and their families pre and post diagnosis. This includes a new speech and language therapy programme for parents and child, as soon as social communication needs are identified.

Contact:

Dr Shirley Jonathan: 01792 517950

Mrs Leah Watson: 01792 517865

The Transfer of Care, Advice Liaison Service (TOCALS) provides a discharge service in the Minor Injuries Unit (MIU) in Prince Philip Hospital, Llanelli. Historically, Front of House (FOH) professionals were dependent on MIU staff to leave patient details for urgent therapy or Integrated Care Sister follow ups. These patients are then contacted and provided with either telephone advice/signposting or an urgent home visit if necessary.

Since COVID there have been service changes, high turnover of patients and staff shortages in MIU and these referral have reduced. The project was identified to begin a more in-depth screening process where FOH staff identified and screened patients presenting to MIU, completing preventative onwards signposting and to reduce the number of admissions and community services required in the future.

Project Aims:

The main aim of the project is to identify key areas of patient needs to reduce the risk of that patient hitting crisis point and re-attending hospital.

Other aims included:

• Setting up a database to capture the screening information gathered and those contacted.
• Forming pathways to ensure consistency with the screening.
• Creating a screening tool to document the information gathered.
• Targeting those over the age of 60 attending MIU with falls, MSK injuries, reduced mobility & head injuries.
• Creating additional links with community services to maintain patients function at home.
• Evaluating data collected to establish the quality and the benefit of the project.
• Obtaining patient feedback comments to ensure benefit from the service user perspective.

Overcoming Challenges:

The main challenge of implementing this project has been continuously adapting the service as the demands of the hospital changed due to the pandemic progressing and altering. At the beginning of the project there was ample time to set aside time to gather data and complete telephone calls.

By November 2020, with the second wave hitting the country, workload within the hospital increased and there was less time to complete the screening. Due to lockdown, the patients that are now presenting to hospital are more complex in regards to their functional and social needs and are therefore taking up more clinical time. We have developed strategies to overcome time restraints and these include…

Key Outcomes:

The main key outcome established from the data collected within the project demonstrates a significant increase in number of people assessed. This results in an increase of those in which the service is reaching. The total number of patients screened to date is 441.

*Although this states “not counted”, these patients were still sent a letter containing the Delta Wellbeing number should they need support in the community.

Within 9 months of beginning the project there was an average of 49 patients screened and saw an average increase of 43 referrals per month, ranging from an additional 25 to 59 referrals compared to our standard service (see graph below).

Next Steps:

To conclude I feel this project has demonstrated a need to switch focus to preventative care rather than the current model of reactive interventions. The COVID pandemic has created a significant increase in loneliness within the community and those attending emergency departments are now presenting with increased social care needs.

We have already targeted a significant amount of patients in our local area and provided them with not only advice and support but a friendly phone call to let them know that there are people in their community who can help them. By continuing the screening we hope to reach more of those that require support, to complete low level interventions and sign posting to continue to prevent crisis’ in the community and future admissions.

My Exemplar Experience:

Although initially I was a little apprehensive, my Bevan Exemplar experience has been an incredibly positive and beneficial journey in developing my skills as a clinician. I feel fortunate to have been given the opportunity to explore the service development side of this project through the Exemplar project and I feel that I have taken something new away from every session I have attended. It has been a great experience to network with others who are developing other projects within Wales and I hope to maintain these links into the future. I would recommend anyone considering this path to take the leap and become part of the Bevan Exemplar family.

Carol-Anne Davies (Service Lead for Acute Occupational Therapists in Carmarthenshire) Aysha Davies (Senior Nurse Manager for Hospital Flow)

Contact:

Challenges:

• An ‘organically evolved’ PICC and Midline service with resource loaded heavily towards device insertion rather than catheter care.

• Organisational learning hindered by lack of data and data-analysis. The baselines we established during the highly unusual arrangements of a pandemic would be unlikely to represent the typical situation.

• Difficulty ring-fencing time in busy clinical schedules to deliver and participate in the virtual ward rounds, education, and programme promotion.

• Managing the increased demand for clinical trouble-shooting that arose as motivated and educated staff recognised adverse events and requested help more frequently.

• 120 patients admitted to the virtual ward

• Delivery of 34 ward rounds over a period of 40 weeks with an average of 20 patients per ward round

• A Monday-Friday 9-5 troubleshooting & advice service established

• A successful and highly interactive on-line showcase event catalysed the development of our network of ward and community team PICC and Midline champions

• An education programme that has already delivered more than 20 training sessions reaching more than 70 primary and secondary care staff members with direct responsibility for PICC and Midline care. Post-training evaluation of their confidence providing 11 basic PICC and Midline care interventions showed an average improvement from 42% to 88%.

• A database developed to record all substandard care and adverse catheter events

• Many clinical practice developments e.g. Clearer catheter labelling, use of skin glue reducing early dressing changes and hospital attendance for oncology patients, reduction in catheter redundancy as staff are confident removing devices, reduction in the use of double-lumen lines when incident analysis suggested an association with catheter-related blood stream infection.

• Many more catheter preservation interventions and much earlier recognition and management of complications

Next Steps:

• Our goal is to provide more frequent ward rounds and a 24-7 troubleshooting service.

• We will engage with patients to empower them as champions of their own catheter care.

• We will promote our catheter preservation programme through showcase events, social media and an intranet website

• We will analyse our dataset to quantify substandard care and adverse events and reveal opportunities for clinical practice improvement.

• We will package the effective elements of our project as a formal catheter preservation programme that could be adopted nationally by a network of teams committed to improving the patient experience, sharing data and setting standards.

Bevan Exemplar Experience:

Being a Bevan Exemplar gave me the tools I needed to transform a personal aspiration into a multidisciplinary project with momentum.

Contact:

Project Aims:

If we are maximising opportunities to keep people at home, how can we understand the ‘ask‘ and demonstrate improvement?

Increasing Time Spent at Home for frail older people is dependent on a complex adaptive system across health and social care working optimally across all system components. We aim to bring simplicity to that complexity by ensuring all organisational directorate, division, service etc focus on one outcome indicator for that population group and that is increasing Time Spent @ Home. Each service should focus on implementing best practice and this is measured. The collective impact of this integrated focus on delivering population outcome will turn the trend on that outcome indicator over time.

• Meaningful measures will enable all partners across the whole system to;

• Establish a baseline measurement.

• Understand activity.

• Improve performance.

• Develop infrastructure and workforce.

• Evaluate initiatives

• Reduced commissioning of ‘formal’ care & support

• It aligns with our heath boards transformation strategy ensuring a visit to hospital is available when individuals need it and with a length of stay as short as appropriate. Achieving this goal will not be possible without seamless working across the system with our partners.

Key Outcomes:

Increasing ‘time spent at home’ for our population will;

• Reduce bed days in hospital

• Improve ‘front door’ performance

• Improve access to emergency services

• Improve referral to treatment times for planned procedures

• Reduce commissioning of care and support

• Reduce delays on discharge

• Maximise availability of finite care resource

Feedback:

Next Steps:

Bring together programmes of work into a cohesive whole system programme and the relevant governance and management structure to deliver effective transformational change efficiently, effectively and sustainably;

• Transformation Fund

• Integrated Care Fund

• Unscheduled Care Winter Plan

• Urgent Primary Care Pathfinder with Primary Care colleagues

• Same Day Emergency Care Pathfinder

• Contact First Pathfinder with Welsh Ambulance Service Trust

• Physician Triage, Assessment & Streaming with Welsh Ambulance Service Trust Pathfinder

• Frailty / Dementia/ Palliative Care & End of Life Care Plans

Our Exemplar Experience:

The support from the specialist advisors taught me to hold my nerve and never be afraid to be passionate about & ambitious to take on the difficult tasks – if it’s ‘the right thing to do’.

Contact:

Alison Bishop: Alison.bishop2@wales.nhs.uk

Recovery through activity (RTA) is an occupational therapy group intervention usually facilitated on a face to face basis. The intervention introduces service users to a wide variety of activities available in their local community to enhance health and wellbeing.

The pandemic has promoted creativity in discovering virtual solutions to delivering interventions, and connecting individuals with online resources that they can access safely from home. Occupational Therapy leads across Wales, developed a standardised protocol for virtual delivery of RTA with an agreed set of evaluation tools. This would enable all health boards to compare outcomes and build a robust evidence base.

Project Aims:

• To enlighten individuals on the benefit of activities for health and wellbeing

• To provide an opportunity for individuals to explore/ try out new activities for health and wellbeing

• To enlighten individuals on the benefit of activities for health and wellbeing

• To create a virtual version of RTA that is accessible to all despite the Covid restrictions

• To provide individuals with early access to Occupational Therapy input regardless of their condition or stage within their recovery process

• To develop an evidence based Occupational Therapy group intervention which could be facilitated centrally to cover a wide geographical area.

• To raise awareness of online resources available to support individuals to carry out meaningful activities and provide opportunities for individuals to connect with others

• To have a standardised protocol with nationally agreed outcome measures for delivery of RTA across Wales with the opportunity to build an evidence base for RTA group interventions

• Improve number of referrals to Occupational therapy from other members of the multidisciplinary team by developing a website and downloadable materials.

• RTA strengthens joint working between statutory and third sector services making the best use of community resources and ensuring that people can access the right support at the right time, a key element of prudent healthcare

Challenges:

• Technology barriers – including Internet Connectivity, Finding suitable venues for staff to comply with covid, confidentiality, and ergonomics whilst facilitating the group, identifying an appropriate online platform that complied with confidentiality guidance and confidence of staff and participants using the technology. The latter was resolved by arranging in service training sessions with staff, and offering one to one sessions for participants.

• Complying with information governance guidelines across health boards – this was overcome by liaising with Information Governance teams in each health board.

• Sourcing funding for one of the key outcome measures – which was overcome through good communication with operational managers

• Lack of funding for developing a website

Key Outcomes:

• Developing a virtual RTA course provides individuals with a choice of intervention methods i.e face to face or virtual, 1:1 or group work; and is therefore more client-centred

• Improved accessibility to those earlier on in their recovery journey who may not feel ready to attend a face to face group

• Introducing individuals to online resources that they can engage in within their own time, which has been particularly important during the pandemic

• Using an agreed protocol and outcome measures enables the health boards across wales to produce a robust data set of outcomes that are comparable

• More sustainable delivery model as can be delivered centrally across a wide geographical area

• Enabled staff to build their technology skills within a short timeframe and put these skills into practice

• Improved understanding of the value of meaningful occupation across multidisciplinary professionals and increased referral rates to occupational therapy.

• Provided opportunities for occupational therapy staff to work collaboratively on an all-Wales basis.

Next Steps:

We aim to roll out the virtual RTA programme across mental health and learning disability services throughout Wales.

We will work with Cardiff University to analyse the qualitative and quantitative data to evaluate RTA and improve occupational therapy interventions, sharing the evidence from RTA interventions widely. This evidence base should enable us to influence the recruitment of additional Occupational Therapists within mental health to deliver RTA interventions.

We also hope to complete the RTA website to raise the profile of RTA across the multidisciplinary teams and improve accessibility to occupational therapy for all.

Our Exemplar Experience:

This experience has put occupational therapy on the map, provided excellent training opportunities and enabled us to work collaboratively across Wales.

Contact:

Nicky Thomas: nicky.thomas@wales.nhs.uk

As part of this work, we wanted to assess the positive impact PhysioNow could have on:

• Patients

• Clinicians

• The wider healthcare system

Problems we aimed to address:

Owing to Covid there have been delays to patients accessing services creating a significant accumulation in demand for MSK services.

By delivering and implementing tools such as PhysioNow, there is a significant opportunity to help and support colleagues in general practice and secondary care, to the betterment of patients.

Challenges:

We had some initial challenges as operational and clinical staff in both Health Boards were redeployed to battle Covid based activities. Once these pressures began to ease, we were able to use PhysioNow and achieve some of the fantastic results evidenced below.

The Results:

Patients

81% of respondents would recommend PhysioNow to their friends and family. Some of the key words repeatedly used by patients are below. The bar graph shows some of the reasons why so many patients loved using PhysioNow.

The wider healthcare system:

The introduction of PhysioNow into an average sized Health Board with standard physiotherapy activity has the potential to create efficiency and productivity improvements of over £300,000 per annum. If implemented across Wales, the benefit would reach well over £1 million per year.

34% of patients completed PhysioNow outside 09:00-17:00 including weekends and Bank holidays when typically, MSK physiotherapy appointments are unavailable.

This ability to provide around the clock assessment and guidance to patients has numerous benefits:

• No need to sacrifice work or family time to attend appointments

• Patients benefit from a safety perspective as well as convenience.

Feedback from Key Stakeholders:

PhysioNow is constantly evolving, and the ‘self-management’ outcome is one such area Connect Health are developing extensively and is ready for imminent roll-out. This will empower patients to manage their conditions without the need to directly interact with services where appropriate. A comprehensive suite of resources will be provided to guide patients on the road to recovery and be monitored every step of the way.

The technology underpinning PhysioNow is constantly advancing and a move to a more interactional chatbot experience is also due for forthcoming roll-out. This will enhance the patient experience whilst ensuring PhysioNow remains at the cutting edge of digital technology.

Our Exemplar Experience:

We really value the opportunity to showcase our work as a Bevan Exemplar. We all would love to continue to receive the support of the Commission for any future adoption and spread.

Further Information: