Alison Bishop and Meinir Jones (HDUHB), Rhian Dawson (HDUHB and Carmarthenshire County Council) and Martyn Palfreman (West Wales Care Partnership)
Hywel Dda University Health Board in partnership with Carmarthenshire County Council and West Wales Care Partnership
A New Approach Improving Whole System Unscheduled Care
Background:
You never know when your last 1000 days will start. But when it does start, would you want to spend it stuck in a hospital bed, or spending your valuable time at home with the people you love?
Older people tell us ‘what matters’ to them is to retain the maximum independence possible and remain at home as long as possible.
As a region we are committed to increasing this time spent at home for our population which is even more pertinent given that in our region we have an aging population that is above the Welsh average for over 65 year olds with a projection that by 2040 a third of our population will be over 65.
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.
Challenges & How We Overcame Them:
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:
‘Working effectively across our agencies to help keep people safely and independently at home for as long as possible is a key priority for partners in West Wales. It’s what people want and it is crucial for their wellbeing. The Health Board’s health and care strategy, our Healthier West Wales transformation programmes, numerous schemes funded through the Integrated Care Fund and an ongoing focus on improving our Discharge to Recover and Assess pathways will help us achieve this. By accurately tracking progress across the system and being able to understand our performance at any one time will help ensure we learn from what works and what doesn’t and focus on the right things. That’s why the Increasing Time Spent at Home, Well & Independent project is so crucial and timely in helping us deliver the improvements we all want to see.’
Martyn Palfreman, Head of Regional Collaboration
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’.
