Page 143 - PROOF_ENG

Offer 2: Help when you need it
Here care and support is designed to support people to regain their previous level of independence after an illness or injury, which include reablement and rehabilitation at home. Examples include:
• Rapidaccessdomiciliarycareprovision
• Acuteresponseteamstofacilitaterapidnursingneedsinthecommunity
• Equipmentprovision,telecareandtelehealthandhomeadaptations
• Housingrelatedsupporttomaintainindependenceathome
• Supportforcarers
• Residential reablement placement in care homes and rehabilitation facilities in
community hospitals
• Anticipatory care processes such as multi-disciplinary meetings and proactive
care-planning
• Targeted projects funded by the Intermediate Care Fund to build effectiveness in
intermediate care, such as TOCALS – a frailty discharge service aimed at facilitating effective and appropriate discharge from hospital
The WG’s Intermediate Care Fund has provided resources to develop new, integrated approaches to care and ensure a level of consistency across the region in relation to key aspects of care and support.
Analysis shows that this tier accounts for the second largest proportion of the overall budget in the region at between 4 to 13% (Fig 32). This however does not consider the significant investment of ICF funds which amounted to £8.4 million in 2014-15, some of which supported projects aimed at improving intermediate care and reducing reliance on acute services.
141
Case Study
Multi-disciplinary Teams (MDTs) and Stay Well Plans in Carmarthenshire
Effective anticipatory care of frail older adults was identified as a priority in the 2Ts GP cluster of Carmarthenshire. In partnership with integrated health and social care teams an MDT approach was embedded to manage frail patients more effectively and pro-actively in their own home will enhance their experience of care, improve their outcomes and reduce acute care costs and bed days. As part of the project, practices nominated a clinical frailty lead and to identify frail patients utilising a practice based IT Risk Stratification System. The MSDi (software) tool is then used to risk stratify patients. Patients identified receive a written Stay Well Plan which includes details of a carer, health and social care summary, optimisation and maintenance plan, and escalation and urgent care plan.
West Wales Population Assessment March 2017 Older people