Section 1: Frail and Older People Total region allocation £4,064,920 (Net, after deductions for regional programme coordination and Carmarthenshire area coordination) 2016-17 funding allocation – ICF Guidance refers Identified services to support delivery of ICF objectives – ICF Guidance paragraph 2.2 refers End of year projected Outcome(s) for each service (col 2) Actual Outcome(s) to date Expenditure to date Additional Information £100,000 Third sector led community prevention model (Carmarthenshire) Reduced demand for urgent hospital care Reduced number of readmissions Increased social impact Better self-management Reduction of social isolation and loneliness Effective engagement of vulnerable groups Q4: All recruitment complete CUSP model agreed by identified partners Specific dementia preventative model established and put into place. Outcome measures agreed and measurement tool implemented. Professional launch 05/2017 Q4 £110,000.00 Project was £10,000 over spent due to the agreement to pay British red cross to develop an outcome measurement tool. Overspend agreed by Project Board & minutes to support decision available. £56,919 Vascular and diabetic foot pathway (Carmarthenshire) Improving health and wellbeing and reducing preventable heart attacks, strokes and leg amputations. Reducing demand on health and social care Improving quality of life for patients Q4: All staff recruitment achieved. We have employed 3 x band 6 and 1x band 7in post. Staff training underway. Two day training and pathway conference organised bringing together Podiatrists, Vascular Surgeons , nursing staff from HB and ABMU HB to develop the Above. Protocols being developed and evidence based practice rolled out. Specific diagnostic clinics set up and prevention programme in development. Project on target and, ongoing and recurring. Q4 £27,844.19 Project was £29,075 under spend as at end of year due to recruitment issued. This underspend was re-allocated within the revenue programme. £100,391 Community Resilience Coordinators (Carmarthenshire) Improved wellbeing of people in Carmarthenshire in need of care and support, through: Enhanced understanding of local community assets and resources, Q4: Carmarthenshire is Kind event delivered with 350 participants to deliver an asset based approach Q4 £64,166.16 Project was £36,225 under spend – this is due to the inability to recruit the third post despite two
(Carmarthenshire) Reduced night admissions to hospital Appropriate training delivered to all out of hours social work staff £5,000 to purchase additional Dietetics support for the Frailty Support Workers (this will be offset by current slippage in the project due to delays in recruitment) £8,147 for TOCALS for uplift of the current 0.8 fte Band 6 DLN to full time (offset by current slippage in the project due to delays in recruitment) £250,000 – Continuing Care Team & Convalescence Beds (Through remaining slippage in the TOCALS Team and Community Proactive Care Team to support winter pressures) £18,550 Healthy Activity Coordinator for older adults (Carmarthenshire) Increased number of NERS (National Exercise Referral Scheme) referrals Q3: Coordinator appointed to post in November 2016, networking, planning and gathering knowledge on building a sustainable service for Frailer Older Adults in Carmarthenshire. Q3 £0 Q4: No expenditure in 16/17 due to the late appointment of the post holder and the HB core grant that supplements ICF funding covering all salary costs. Postholder is now in place and full outcomes will be reported in 17/18. Q4: £0 £56,920 Additional OT reablement capacity (Carmarthenshire) People receiving service are functionally more independent and less dependent on statutory services Q4: All 3 OT’s are now in post and have started attending weekly pathway meetings and taking on Reablement referrals. Outcomes will be reported in Q1 17/18. Q4 £0
less per week which equates to a 11% reduction. complement of staff. Outcomes will continue to be reported, including those missing, during 2017/18. £500,000 Rapid Response Domiciliary Care Service (Carmarthenshire) Number of people receiving an intervention from the RR service Number of avoided hospital admissions by RR Number of safe hospital discharges achieved by RR Numbers of people responded to by RR due to Telecare Alarm alerts (To be discussed following outcome of Reablement Review) Q4: 204 people receiving an intervention from the RR service 94 escalations of care, including hospitals admissions avoided 3 people supported early hospital discharges 83 responses from the Telecare alarms Q4 £500,000.07 Project achieved full spend – original figure is incorrect. Original allocation was £500,000, not £527,000. £636,305 Transfer of Care Advice and Liaison Service (TOCALS) (Carmarthenshire) Reduction in the number of admissions and re-admissions into acute care Decreased length of stay on admission Q4: Number of TOCALS assessments completed: PPH –237 Number of patients discharged within 24 hours: PPH – 46 GGH - Number of patients discharged at the ‘front door’ : PPH - 68 GGH Q4 £574,567.24 PPH – Locum PT recruited for March, Full time PT recruited and due to commence in post May. Second DLN commenced in January. £77,760 Increased OT and physiotherapy capacity (Carmarthenshire) Reduced length of stay on medical wards Integrated assessment completed within 72 hours of ‘medically fit’ judgement Increased satisfaction of users and carers Q4: Update to follow Q4: £207,127.71
Multi-factorial Falls Risk Assessment tool finalised Contribution to Falls Prevention education of Care Home staff in South Ceredigion Physiotherapy brief intervention falls “care bundles” developed for use within Physiotherapy service as adjunct to SAS clinic Referrals received to end March North = 2 Referrals received South = 1 Patients seen and managed within clinic = 1 £241,430 Interim Placement Scheme (Ceredigion) Improved patient flow for Ceredigion residents who have been admitted into acute hospital. Admission avoidance for Ceredigion residents who use the scheme and remain closer to home. Appropriate timely assessment reducing the admission to nursing / residential care on discharge from hospital / the scheme. Q4: Number of new admissions: 14 Hospital avoidance: 9 Timely discharge: 5 Number discharged: 15 Nursing care: 6 DGH: 3 RIP: 2 Home: 4 Q4 £264,250.72 £139,260 Review of high cost packages (Pembrokeshire) People are supported with maximum care that meets their individual needs and maximises independence Q4: Employment of a full time project OT enables a dedicated project assessment and review process and drives cultural change to support project progress Cultural change is being supported at every level. Well-established and attended Project Enablers Group meets every month to support system redesign. 14 clients have had care packages reduced to single handed care as a direct Q4 £40,420.80
New documentation has been developed to support the project, including a shared Moving & Handling risk assessment Equipment to support single handed care provision for individual use and for training purposes has been purchased. £234,836 PIVOT, Care and Repair and Community Support Workers (Pembrokeshire) Inappropriate admissions avoided Timely and effective discharges Improved opportunities for independent living in the community Improved quality of life for service recipients Improved integrated working with the 3rd sector Reduction in social isolation for individuals Q4: 1300 bed days saved 130 admissions avoided 100% of recipients said that the service has made things better 196 individuals supported by Community Connectors to meet identified wellbeing goals Q4 £240,520.00 £30,000 Community innovation and resilience grants (Pembrokeshire) Increased community capacity to support independent living Q4: Q4: A total of 6 grants panels have been held, and a total of 22 grants have been awarded. 14 grants were awarded to projects and organisations working with older people, to a total of £24,640 6 grants were awarded to projects and groups working with people with Learning disabilities, to a total of £16,166 Q4: The increased assessment capacity has facilitated a more person centred approach, which has delivered better value for money. For further updates on this Q4 £27,040.00 Projects awarded with funding will report their outcomes by the end of April 2017 whereupon a full report on the outcomes and achievements of the CCIG will be made available.
National Measure: Rate of delayed transfers of care per 1,000 population aged 75+ [StatsWales is source] Wales 15/16 average is 4.90 and Wales 15/16 top quartile is 2.4. Q1 = 0.52 [7] Q2 = 1.55 [21] Q3 = 2.07 [28] Q4 = 2.96 [40] We report on reablement on a monthly basis to our health colleagues by way of a reablement dashboard £30,553 Push/ pull post for reablement/ hospital interface (Pembrokeshire) Individuals enabled to regain/ maintain optimum independence Control, choice and dignity in care LA care resources used effectively Reduction in care provision for individuals Efficient use of staff knowledge, skills and capacity Reduced risks with moving and handling HB resources shifted towards community from acute provision Released resources and capacity Q4: Review workers are in place, also supplemented by PCC funded worker 66 people receiving service during last day of period 4 weeks is average length of reablement intervention 66% of people complete the service with no ongoing care needs. Review workers continue to support flow through the service and timely discharge to domiciliary care providers when needed which maximises availability of the service, which in turn supports the delayed transfer of care / patient flow agenda from hospitals. Q4 £30,247.46 The average length of a reablement intervention has decreased from 6 weeks in 15/16 to 4 weeks in 16/17. The average for March 2017 is 3 weeks which suggests further improvement in the management of flow through the service. This should be viewed in conjunction with the positive outcomes with 66% of service users leaving with no long term domiciliary care at the end of 16/17. £254,000 Multi Agency Support Team (MAST) (Pembrokeshire) Reduction in hospital admissions Improved personal and functional outcomes for people using the service Q4: 240 assessments undertaken by MAST 59 assessments undertaken at weekends or bank holidays. 61 % (142) of those assessed not admitted to acute care. Q4 £271,091.60 “Thank you for coming so quickly, we have been reassured by your assessment and advice, dad was
standard is already driving up the standards across the sector. An outcome based specification has been provided to service providers for review and broadly agreed. Way forward: Commission a framework of providers – carried over from this year as the market was not ready for a tendered process. Total Q4: £432,238.11 Section 3: Other (Revenue) Total region allocation £80,786 2016-17 funding allocation Identified services to support delivery of ICF objectives – ICF Guidance paragraph 2.2 refers End of year projected Outcome(s) for each service (col 2) To date – actual Outcome(s) Expenditure to date Additional Information £75,000 Financial and programme coordination and evaluation (Whole region) Effective coordination of programme and evaluation of impact Q3: Post allocation process facilitated. Regional Q3 Report produced Monthly finance reports produced Q3 Q4: End of year process facilitated. Report produced Q4 £68,774.67
(Whole region) Increased no. of children receiving appropriate behavioural support Improved family experience of accessing support Reduced waiting times for specialist behavioural intervention Q4: funding reallocated to other ICF programmes within WW region. Q4:20,000 £0 Funding re-allocated due to late start. £200,000 Integrated Community Equipment Service (Carmarthenshire) Citizens are safe in their own homes as a result of equipment being provided by Carmarthenshire Integrated Community Equipment Stores (CICES) Citizens stay at home during an incident or illness, rather than entering a hospital, as a result of equipment provided by CICES. More patients have a swifter discharge from hospital back into their home environment, as a result of equipment provided by CICES prior to discharge. Citizens can remain in their home for as long as possible before transfer to a residential home setting, using equipment provided by CICES. Q4: Smaller items such as bathing and toileting equipment purchased this quarter has allowed patients recovering from an operation return home at the earliest opportunity. This equipment also allows patients to stay safe in their own home. £200,000 Q4 £338,523.00 Hundreds of individual items were purchased as part of this project with dozens of different equipment types purchased. In particular, community profiling beds, dynamic mattresses and hoists allow patients either to remain at home or leave a hospital setting at a much earlier date. Each time a dynamic mattress is delivered for someone leaving hospital, this must allow the patient to leave at least three days earlier than they otherwise would. For the 30 beds and 30 mattresses purchased as part of this project that have
placements and subsequent hospital admissions. Ensure local community provision is robust enough to support a community based step down package by providing skilled and confident staff with the right resources in the right place. Ensure the least restrictive option of support is available, which is focused on individual’s strengths. £123,923 Transfer of Care Advice and Liaison Service (TOCALS) (Carmarthenshire) Reduction in the number of admissions and re-admissions into acute care Decreased length of stay on admission Q1: Project initiation on hold pending WG approval of Capital bids £123,923 Q1: £0 Project not approved. £120,000 Carmarthenshire Independent Living Centre (CILC) (Carmarthenshire) Citizens are aware of C.I.L.C and what it can do for them. Citizens have a greater choice of options to help them with their daily living. Professionals have a centre that they can use to demonstrate large equipment and re-assure families who have to have significant support in their lives. Support services are relied on less, as different types of equipment and assistive technology in particular, are used by individuals which can reduce dependency on formal and informal carers. The centre becomes self-funding – it should also be recognised that the centre should make “savings” in other Q4: All works completed by the end of March 2017 with contractors visiting after the project end to liaise with the Project Manager to ensure sign off. The work has been completed in accordance with the project plan and to a high standard. The completed project has seen the creation of a large demonstration / display room that can be used by prescribers and the general public to see how community and Telecare equipment can enhance peoples’ lives and will showcase what is available to the public through the Health Board, Social care and what can be purchased in the market place. A new training room has been created so that prescribers and members of the £120,000 Q4: £98,264.08 Alternative proposal for TOCALS. CILC has started taking meeting room booking for 2017 and has had many pieces of equipment donated for use in the demonstration rooms. Visual and hearing impairment equipment will also be displayed at the centre. A publicity campaign will take place in mid-May which will promote the centre and its use
Reduction in social isolation for individuals External rail – 11 Fire safety check – 15 Shower seat – 6 Lever taps – 1 Steps – 1 Electrical work - 1 Q4 A total of 108 referrals have been responded to during the year either through the PIVOT Caseworkers or from Home Safety Checks provided within PIVOT. £30,000 Community innovation and resilience grants (Pembrokeshire) Increased community capacity to support independent living Q3: 3 panel meetings have been held so far and grants totalling £18,310.56 have been awarded £30,000 Q4: A total of four panel meetings were held throughout the year and capital funding totalling £30,000 was allocated across 12 different projects Projects awarded with funding will report their outcomes by the end of April 2017. A full report on the outcomes and achievements will be made available. £84,000 Community Equipment (Pembrokeshire) More people supported to live at home Increased independence and quality of life for individuals Q4: 25 clients supplied with bath hoists or bathing cushions provided a quick, effective response to meet needs and are also a cost effective alternative to adaptations. 18 clients provided with specialist beds and seating and 30 ‘Sara Steadys’ and 10 profiling beds and air mattresses were supplied to support living at home and increase independence. £104,000 Q4: £90,000.41 Increase in projected expenditure as a result of projects not being approved.
£128,000 Central review Teams (Adults) (Carmarthenshire) Those who use our services contribute to the review of their support and services enabling choice and control. Independence maximized and enhanced self-determination of individuals accessing services To realise cost savings by right sizing packages and placements. Q4: Due to delays In recruitment, the post holders have only recently commenced in post. The Nursing and Social Work elements are now in place and will begin to deliver outcomes as stipulated. We are also currently in the process of appointing 4 reviewing officers who will support the social workers and nurses to develop this scheme further. Q4: £0 £128,000 under spent. £35,000 of this funding was re-allocated to the slippage scheme to employ two right sizers to look at high cost packages of care and realise cost savings where possible. The remainder of the funding was within the revenue programme. £90,000 Additional step-up/step down beds (Carmarthenshire/HDUHB) Maintenance of wellbeing and independence Decreased requirement for formal social care and admission avoidance Q4: During the period of use, 5th December 2016 – 31st March 17, a total of 33 individuals accessed the beds to facilitate hospital discharge. Average length of stay of these individuals is 23.1 days (range 3 – 42 days). The evaluation of the project resulted in decommissioning with one care home and re-commissioning 10 beds with the other care home, with revised eligibility criteria, for a further 10 weeks. A further evaluation will be carried out at the end of May. Q4: £101,639.76 Project over spent by £11,640 – over spend agreed through project board. £10,000 Physical Activity Pathway for health and wellbeing (LD/ complex needs) (Carmarthenshire/HDUHB) TBC Q4: Equipment has been purchased with support from Physiotherapist. The room is currently being prepared. Individual programmes are yet to be developed. Baseline information will be recorded for all individuals who will be accessing the facility. This information will be available for evaluation 20017/18. Q4 £7,040.00 Further work will be needed to the grounds surrounding the building. This will support access for people who have more profound disabilities. The possibility of creating additional bathroom facilities for that part of the building is also being explored.
convalescence/reablement without ongoing services. Reduce level of support needed following residential convalescence/reablement intervention. translates to a cost saving of £395.13 per day/night and therefore, over the course of a year, would mean a cost saving of £1.89 million to the NHS. £96,000 Additional nursing bed capacity (spot purchase - admissions avoidance) (Carmarthenshire HDUHB) • Maintenance of wellbeing and independence • Decreased requirement for formal social care and admission avoidance Q4: Realisation of flow through the system from acute to community. The integrated assessment nurses are now in reaching into the acute areas to facilitate the spot purchase of these beds. During 2016/17 20 beds were spot purchased in Nursing homes in Carmarthenshire to support individuals to be assessed in an appropriate environment. 3 of these were deceased before the MDT 5 of these were deemed to have needs that could be met by CHC and 12 met the eligibility for FNC. A report of outcomes achieved is available Q4: £96,000.00 £26,250 Enhanced Acute Response Team (Carmarthenshire HDUHB) Avoidance of admission which promotes independence Decreased requirement for formal social care Q4: Recruitment complete & appointments have been made and commenced in post during March. Outcomes will begin to be evidenced in Q1 17/18. Q4: £5,962.59 £20,287 under spent due to inability to recruit majority of posts during financial year. £35,000 Positive Behaviour service - rightsizing capacity (LD / complex needs) (Carmarthenshire HDUHB) Q4: Two post have been appointed to look at rightsizing care packages to ensure they are fit for purpose for the individual and to also look at realising cost efficiencies. Q4 £35,543.77 Case Study: A young lady in her early 20s, was placed in a residential setting in a crisis scenario and unfortunately remained there for 2 years. With the support of the team she is now being stepped down to a supported living arrangement
Cost efficiencies of £700,000 have been achieved since December 16 (£450k LA & £250k HB) with 3 other transition clients of a similar age, with all the opportunities and benefits this less restrictive option offers. In addition this has been achieved with a significant financial saving to the commissioning authority. ARCH Consultant - Ian Lancaster Watts (Carmarthenshire) Q4: Q4 £10,475.00 Slippage scheme. Rehabilitation Ward 9 (Slippage) (Carmarthenshire) Functional outcomes via Goal Attainment Scale Length of Stay Admission and Discharge modified Rankin score Patient experience Qualitative & Quantitative questionnaire Patient Stories Q4: Q4 £14,195.00 Slippage scheme. £10,000 Pathway planning analysis - Amman Valley/Llandovery (Carmarthenshire HDUHB) £0 This is now being led regionally and no longer funded on a County basis. £20,000 Third sector community resource team (CAVO) Establish a Third Sector Community Resource Team which will allow the statutory providers to determine patient / client needs and ‘spot purchase’ services to meet those needs. Develop sustainable practices for Third Sector Providers which meet the needs of changing and evolving needs of patients / clients in Ceredigion. Q4: : 3rd Sector Core Community Resource Team indicators; Number of clients - 107 Number of interventions initiated - 471 Time spent to date - 50.2 hours Links created with AA2A as key referral route. Joint working processes established between team partners. Q4 £20,000.00 £8,980 Rally Round (CAVO) Integrate Rally Round as a tool for use by the Third Sector Community Q4: Rally Round purchased and implementation proposal devised Q4 £8,980.00
community services and will inform further development of the AA2A and Discharge Liaison Services. £20,000 Community Frailty Service (Pembrokeshire/HDUHB) Q4: Frailty services extended across South Pembrokeshire. Commenced service in North Pembrokeshire in September 2016 working closely with GP partners, social care and health multidisciplinary team to ensure equity of access County wide. A&E Frailty audit undertaken to review patients suitable for frailty assessments. Ongoing development of service to NHS. commissioned beds, care homes and Hillside Intermediate beds. Appointment of an additional Band 7 Frailty Nurse Practitioner post. Full review of service embedded with Case study. Q4 £20,000.00 £20,000 Discharge liaison nurse/ coordination of assessment beds (Pembrokeshire/HDUHB) Q4: Additional capacity of 1 WTE Band 6 Community Hospital Discharge Liaison Nurse to complement the Acute Hospital Team. DLN team now integrated across acute/community providing Q4 £20,000.00
£17,000 Trusted Assessor and Referral Training (Pembrokeshire/HDUHB) Q4: 2 day trusted assessor training delivered to staff across health and social care. Feedback from participants extremely positive. Participants now able to safely prescribe range of daily living equipment without person requiring additional OT assessment, improving timely response, reducing risk and duplication of assessment. Q4 £0 £40,400 MAST - nurse/ social worker at front door of acute hospital (Pembrokeshire/HDUHB) Q4: Additional District Nursing Band 6 1 WTE has facilitated District Nursing presence on all weekends and Bank Holidays in Q4. The Additional District Nursing capacity has facilitated greater liaison with the hospital Discharge Liaison Nurse Team, Joint Discharge Team and Complex Care Team in terms of in-reach to acute wards for patients assessed at A&E / ACDU. 232 assessments were completed in A&E/ACDU by MAST, with 142 patients (61%) of those assessed not requiring admission to an acute hospital bed. A further 211 patients received post-discharge support by the MAST team. 59 assessments were completed on weekends / Bank Holidays. All 232 had District Nurse input according to identified need. Q4 £29,885.99 Comments received: “Couldn’t thank enough – didn’t expect such good service on a Sunday!” “Impressed by the team who were able to assess what I needed so that I could go home”. “A good thorough service. Surprised dad came home on a Saturday but he is much better. Lovely to receive the follow-up call, thank you”. £185,000 WCCIS Q4: Q4 £189,459.00
limb vascular assessment held for staff on 3rd and 4th April 2017. Acute Response Team (ART) (Pembrokeshire) Q4: ICF investment has facilitated the recruitment of an additional 1.88 WTE Band 5 Nurse, 1.4 WTE Band 3 Nurse and 0.53 WTE Band 3 Admin & Clerical support, which represents a 17.8 % increase in ART’s staff capacity. Additional staff capacity has resulted in increased ART patient activity over the past few months. In January 2017 the service responded to a record 187 referrals, the typical average for October 2017-March 2018 being 150, ranging between 125 and 187 per month. The additional staff resource has facilitated development of a ‘Coordinator’ role within the service which is now pivotal in supporting ART’s effective liaison with acute ward areas, GP’s, community teams, the hospital Joint Discharge Team / Discharge Liaison Team etc. This effective liaison now sees ART directly involved in proactively identifying patients suitable for referral to ART and overseeing the coordination of timely acute hospital discharge / uptake to the service from the community. Q4 £54,057.75 Comments received: “You have played such a major part in my recovery and rehabilitation over the last 11 weeks and for that I am truly grateful”. “Thanks for your kindness and concern over the past 6 weeks – without your service I would probably still in hospital in Cardiff instead of the comfort of my own home”. “Your service meant I could leave hospital earlier and be with my young family”. “Thanks, your service prevented my elderly mother from needing to be admitted”. “This service makes total sense, right care in the right place!”