Integration between health and social care is a key driver in current national policy. Welsh Government set out its requirements for integrated health and social care in “A Framework for Delivering Integrated Health and Social Care for Older People with Complex Needs” and early in 2014, Conwy and the other five North Wales’ Local Authorities with the Betsi Cadwaladr University Local Health Board (BCUHB) agreed the future framework for the delivery of integrated Health and Social Care for Older People with Complex Needs and issued a Statement of Intent.
The primary purpose of Integrated Care is to ensure that our citizens have a better experience of care and support, experience less inequality and achieve better outcomes. Integrated services are being promoted as an appropriate service model to deliver shared care to those client groups likely to be high users of health and social care services such as older people.
Promoting people’s well-being is a key aspect of the change needed in the model of care across Wales. To this end local authorities and LHBs are expected to work together to develop and introduce common arrangements to enable an older person in the community, residential care or hospital to get advice and information from professionals to help them promote their well-being.
In Conwy, we have established a Memorandum of Understanding (MOU) with BCUHB. This MOU seeks to clarify respective roles and responsibilities of both Conwy County Borough Council and BCUHB in the joint delivery of a continuum of community based services that provide a system of community support, early intervention, re-ablement and intermediate care as well as end of life care for the citizens of Conwy.
These services are delivered by co-located health and social care teams comprising of Social Workers, Occupational Therapists, District Nurses and Community Support staff that are based in five different locality based offices. Older Peoples’ services in Conwy have always endeavoured to work closely with primary health care services based around geographical areas and consequently there existed already well established links with health professionals in the community. However, since the development of the multi-agency locality teams at Llanfairfechan, Llanrwst and Llandudno we have seen this develop further. Purely by being co- located in these bases, the relationship between health and social care professionals has improved and we now have staff from both organisations routinely working together to deliver vital community based services for older people living in their respective localities.
The end of life service is a good example of how we effectively deliver these services in partnership with health. Social care community support staff work alongside District Nursing staff to provide support and assistance to people who are at the end of their life and wish to die at home.
What difference has it made?
Below are some case studies showing the difference these co-located multi-agency teams have made:
Canolfan Crwst – joint allocation meeting held every Monday morning , District nurses, Chronic Disease Management Nurse, Community Support Team and SW team attend– new and existing cases discussed, we are fortunate to have a very good working relationship with our health colleagues and we share information and discuss any concerns.
We also have informal discussions day to day due to sharing office at Canolfan Crwst.
Example case studies:
- Whilst client at home there were concerns about her dietary intake. Client was in receipt of support from Dementia Team, District Nurses attended and weighed client regularly and reported back to SW team, which assisted to monitor situation jointly between Health and SSD
- Client discharged from hospital to N/H for convalescence – client wished to return home, but previous concerns re self neglect. Chronic Disease Management Nurse and SW jointly assessed client at N/H and care package arranged for client to return home – both CDMN, SW and Community Support Team will be working together to monitor client’s progress and situation at home.
- Client had skin condition and leg ulcers, legs very oedematous, client received home care support and Chronic Disease Management Nurse attends regularly. During flare up of condition, CDMN and SSD have worked together to arrange respite care with increased support and monitoring at Hafan Gwydir, which avoids client being admitted to hospital.
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