March 2021 Bulletin
Transforming Community Health and Care in Gwynedd and Môn
This edition will focus on the steps that have been taken across Gwynedd and Anglesey to overcome some of the barriers that have arisen in developing the integration work.
With the pandemic at its peak since the start of the year, community based staff and colleagues at the hospitals are feeling its impact more than ever. The ambitious vaccination programme offers hope, but also places pressure on front- line services. Ensuring capacity within the hospitals is vital to safeguard health services, but poses additional challenges for community services.
It is understandable that partners’ ability to commit to the transformation agenda is affected at this time. But despite the challenges, major steps have been taken across both counties, with early efforts beginning to bear fruit, and a robust process is in place to identify and tackle barriers.
The Community Resources Teams in Gwynedd keep a record of the barriers facing them locally on an electronic Blockages Boards. This is about to be introduced in Anglesey.
The main barriers facing the local teams
- Patient Referral: Complex procedure for referring patients from the hospital back to the community.
- IT: Lack of smartphones and/or laptops for community health staff
- Access Point: Lack of a single point of access (front door) to the CRT
- Information sharing: Lack of suitable systems to share information about patients / clients
- Staff Capacity: Lack of capacity or time for team members to commit in full to the CRT’s developments.
- Bureaucracy: Too much bureaucracy and burdensome paperwork
- Covid-19:As staff respond to Covid- 19, and the demands of the vaccination programme, their ability to be involved with the transformation agenda is restricted
- Home care: Lack of home care in specific areas
The CRTs report and present the barriers to the senior leaders every month, whilst also reporting on progress in their area, and the leaders in turn, strive to resolve the most complex issues.
Spotlight on the solutions
Referring patients from hospital back into the community
A project has started to ensure that people can be discharged from hospital as soon and as safely as possible, and that arrangements are in place to coordinate any further care in the community.
Since early February a new process has been put in place to help clients who were receiving home care before being admitted to hospital. Every home care provider has now
agreed to coordinate the arrangements for the discharge of their current clients from hospital to their own homes, without having to receive a referral from a social worker.
Emma Jones from home care provider Plas Garnedd said that their relationship with the hospital was much improved, and that it was possible to get patients home much sooner.
In addition, two pilot schemes are about to commence to facilitate arrangements for the local CRT to discharge patients who require a new home care package back into the community.
The project has also secured ICF funding to assist patients to receive information and support in hospital. Officers from Age Cymru Gwynedd and Môn offer a timely and practical service to help patients to go home sooner, without having to draw-in statutory services.
We’re now in regular contact with staff nurses, ward clerks and even consultants through email, and have a really good relationship with the hospital. We’re all working together as a team, like the CRTs. We know who to talk to now.
Towards one point of access
One of the main barriers preventing further integration work, according to the teams, is the fact that referrals come in from many directions, rather than through a single point. The two counties are addressing this in different ways, and a report will be submitted to the Integrated Services Board in March presenting the proposals from both counties.
Meanwhile, a team of community nurses have received funding to develop ideas for a ‘single point of access’, drawing support from other professions. Learning from this project will be shared and integrated into arrangements moving forward.
Help me live my life as I wish to live
Community Health Staff Receive IT Equipment
Historically, community health workers have been recording most of their work on paper files, and having to rely on returning to the office to input electronic information.
Now, community health staff in the areas of Holyhead and Llŷn can use brand-new laptops to record, e-mail, communicate via virtual meetings, etc.
This was arranged as a part of a project to explore how the WCCIS system can assist to integrate and share information across health and care fields in both these localities.
Further plans to obtain smartphones are also in the pipeline, in addition to identifying ways to tackle Wi-Fi problems in rural areas and GP surgeries.
Improving the Home Care Provision
The lack of home care provision is an issue that has again come to the fore in Gwynedd and Anglesey recently, with recruitment campaigns arranged in both counties.
Whilst Anglesey already has already split the county into three commissioning areas, the plans to redesign home care in Gwynedd are on-going. Pending confirmation the tendering process for patch based contracts should commence in May/June.
In the meantime, between now and the awarding of the new contracts, Gwynedd Council will guarantee a specific numbers of hours per provider based on their share of the current market.
They will be expected to work closely with the Community Resource Teams in each area, as the central brokerage service will wind-up at the end of March this year.
Independent providers and the Council’s in-house service will be expected to collaborate, and discuss with the other CRT members in each area, to manage and meet the local demand. Developing strong community networks is vital, and collaboration with local groups and enterprises in the 3rd and independent sectors will be key in integrating professional and community support.
Developing information sharing systems
The lack of suitable systems and guidance on sharing information about patients or clients is a clear obstacles to the integration and collaboration work.
To address this, the Transformation Team has been ensuring that suitable information sharing agreements are in place to facilitate the developments. A number of projects are being developed to trial ways of sharing the data effectively:
Hospital Discharge: A project to share information between the councils’ existing systems and the health system, to facilitate the hospital discharge procedure.
CRT Storage Sites : Safe sites to retain and share information within each Community Resource Team to avoid duplication between members and facilitate integrated working.
Hospital Hub: Portal to integrate information about patients referred to the hospital discharge Hub.
Health and Care Hub: Gwynedd and Môn health and care hub that will act as a portal to share information about the transformation programme with all members of the CRTs; will hold local CRT information (but no private data) and provide links to the sites mentioned above.
Support to release capacity
It is clear that the challenges posed by the Covid19 pandemic are causing difficulty for Community Resource Team members to fully commit to the transformation programme. But work has started to offer support to manage the capacity within the local team
A number of sessions were held with the Social Services Leaders team in Gwynedd recently. Members of the transformation team have been supporting the services’ senior manager, Mari Wynne Jones to discuss and prioritise the demands on her team.
Mari believes that these session have been really valuable, and a means of taking stock of all the demands that reach the service. “Members of the local leaders team have started to get to grips with their work programmes and their day to day demands,” said Mari, “with the aim of releasing capacity and planning ahead in a strategic way.”
As well as continuing to develop the work-streams mentioned in this bulletin, the Programme will focus on the following priorities during the next period, up to April 2021.
- Incorporating the Operating Model in each CRT as a means of achieving what matters by discussing and tackling measures, barriers, expertise and gaps in services.
- Launching the Sharepoint Health and Care Hub in all CRT areas.
- Establishing plans and resources to develop the work around therapies/equipment, Welsh language requirements, front door models and administrative support
- Adopting appropriate measures to show CRT performance against purpose
- Sharing the WASPI agreement to increase confidence in sharing information
- Implementimg the ‘agile’ method on Anglesey to develop local accountability, strengthen lines of communication and feedback between the teams and senior leaders, and continue to develop the method in Gwynedd.
- Taking steps to ensure that all home care providers are active members of the CRT in Gwynedd.
- Submitting a proposal to the ISB regarding a project to review paperwork/business processes