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Bevan Exemplar Cohort 8 Projects

Prosiect Rhestr y Gymuned Iechyd Integredig / Integrated Health Community List Project

Rhian Green and Meilys Heulfryn Smith

Cyngor Gwynedd

Planning for a patient’s discharge requires community health and social care professionals to know who, on their discrete, collective caseloads has been admitted to hospital, also for the ward to know who in the community is involved. Access to each other’s contact information is also vital.

This project resolves this issue, in real time, and can be expanded to accommodate other identified and future information sharing needs.

The project:

Non-sensitive information held in multiple systems about a patient is gathered, aligned and presented it in one easily accessible space, giving the hospital and the community the necessary information to co-plan the patient’s discharge.

The aim is to facilitate good and productive conversations between relevant professionals, and the individual and his/her support network, in order to ensure the best possible outcomes.


We match and then combine data from CareDirector (WCCIS) and WPAS (Welsh Patient Administration System), using an individual’s NHS number, and present relevant information in a PowerBI table report. Data from Symphony, the patient administration system used in A&E (Ysbyty Gwynedd), is also part of the data matching. Any ward using WPAS and considered a CDU is also in scope (including SDEC).

Individuals with NHS email addresses, including GPs and pharmacists, and whitelisted individuals from the Council are able to gain access to the report dependent on row level security. In line with the WASPI data sharing agreement across north Wales other partners are also able to gain access to the report e.g. home care providers, 3rd sector organisations.

Anticipated benefits:

The aim is to facilitate earlier and better discharges – ensuring the best possible outcomes for individuals – through sharing information in a timely manner.