Cardiff and the Vale Healthcare Community Programme for Health Services Improvement Rehab & Intermediate Care Workshop 19 July 06

 Recap from last time  Integrated Care Pathways  What style of care are we expecting to see at each stage of a care pathway  At what point during a care pathway will the boundary between medical and intermediate care occur  Who are the parties that take responsibility for patient care at each point of the pathway  Modelling activity Today's Workshop

 Definition of Intermediate Care  Service redesign principles  Central Contact and Assessment Centre  Service gaps Outputs from Last Workshop

Routes Into the System

“An outline or plan of anticipated clinical practice for a group of patients with a particular diagnosis or set of symptoms”  allow us to map out the care that is to be given to each patient  provides a multidisciplinary template of the plan of care, leading each patient towards a desired objective  reduces unacceptable variations in treatment  clarifies roles and responsibilities  improves safety, patient involvement and quality of information Integrated Care Pathways

Care Pathways in Intermediate Care  How do they apply to Intermediate Care  What kind of care pathways are there?  Who do they help?  Is there any evidence for them in Intermediate Care?

High Level Protocol

Low Level Protocol

Inpatient Path

Pathway of Care

Type of Care

Style of Care

Points of Transfer

Responsibility for Care

Model of Care for Cardiff & Vale

Services and Settings

Community Map

Geographical Locations

Community Cycle

 Are there any particular inclusions or exclusions of conditions that would be addressed by Rehab and Intermediate Care  Are there any particular inclusions or exclusions of patient types that would be addressed by Rehab and Intermediate Care  Comments on Integrated Care Pathways and what they might mean  At what point during a care pathway will the boundary between medical care and intermediate care occur  What style of care are we expecting to see at each stage of a care pathway  Who are the parties that take responsibility for the care of the patient at each point in their care pathway  How to manage the hand-offs between the different responsible parties  Services and Settings matrix  Geographical Locations matrix Breakout Session

Key objectives behind the proposed changes in the whole system Model of Care  Improve performance to reduce occupancy and create capacity to meet access targets  Emergency capacity to meet 4-hr target  Ring-fence elective capacity to manage waiting lists (Project 2009)  Avoid inappropriate emergency admissions  Improved chronic disease management  Better use of primary care services  Better, more rapid access to diagnostic services The Model of Care : Service Objectives (1)

 Improve the process of discharge and make better use of all parts of the systems to provide integrated care pathways  Manage care locally in the most appropriate clinical environment  Increased focus on the use of community hospitals for active rehabilitation  Minimise delays in discharge and facilitate more longer term care at home and in residential settings  Improves both efficiency and quality, and makes better use of resources The Model of Care : Service Objectives (2)

Making better use of resources

 Analysing Trust data  Current Model of Care and Future Model of Care  Performance assumptions  Growth in activity  Longer term performance Modelling Activity

Next Steps