(WIP) Falls Prevention Programme: Making the Connections. Rhian Dawson, Integrated Health and Social Care Manager, Aman Gwendraeth Locality

Transcription

1 (WIP) Falls Prevention Programme: Making the Connections Rhian Dawson, Integrated Health and Social Care Manager, Aman Gwendraeth Locality

2 Carmarthenshire Position One of three Counties in Hywel Dda Health Board Integration Journey Commenced 2 years ago Section 33 Agreement - Central Referral Point / Comms Hub Three Localities: 3Ts (WWGH), Llanelli (PPH) and Aman Gwendraeth. Each Locality has 8 GP practices

3 Carmarthenshire Position Each Locality has a Community Resource Team (CRT) CRT comprises PT, OT, SW, CCM nurses (3), Telecare Assistant, 3rd Sector Broker, Admin Team, Primary Care Manager Each Locality also has District Nurse Lead for Frailty and Falls (Band 7) Management Generic District Nursing Team Education and Practice Development Complex Case Load

4 Faller Identification / Trigger Bundle A&E WAST Careline Community Resource Teams In House Service Provision (Domicilliary Care / Care Homes

5 West Wales General Hospital A&E n=2982

6 WAST Falls Pathway

7 Lifeline Pendant Careline / Telecare Falls Sensors (Mats, Hips) Sheltered Housing Data Sharing Emergency Services Data Collected Monthly 1,967 client contracts with Careline / Telecare sensors 71 'client fallen' triggers per month (average) Approx 2.56 triggers per day

8 Falls Prevention Everybody s Business Community Care Assessment (SW and CMA) Therapy Domicilliary Care Provision Residential Care Provision Screening for Falls Routine Daily Practice

9 So What? How do we progress to the Assessment, Intervention Bundles? Development of Hywel Dda Health Board Strategy for Falls Prevention and Promoting Bone Health Agreement that MFFRA is a process that takes place across a period of time which involves a number of disciplines WAST, A&E, Careline, CRT member Faller Identification data filtered into CRT Frailty Registers held in each Locality

10 Locality Frailty Registers Locality Register provides opportunity to coordinate and track process of assessment Supports Avoidance of Duplication (i.e referrals) Allows monitoring of Faller Journey and identification of recurrent fallers who despite primary care and community intervention continue to fall Referral to rapid access frailty clinic: Comprehensive Geriatrician Assessment, Diagnostics, Psycho Geriatrician, Dom. Care

11 Primary Care? April 2011 Introduction of new Quality and Outcomes Framework (QOF) indicator known as Quality and Productivity (QP) Targeted development of GP pathways to prevent hospital admissions 2011 / 2012 Development of Secondary Prevention of Falls Pathway Identification of Fallers (Read Coded) and Exclusion of Modifiable Clinical Factors for Falls Prior to Referral to CRT

12 Primary Care Cont d 2012 / 2013 Development of the pathways to focus on Frailty (Falls Prevention, Dementia and End of Life) Continued Read Coding of Fallers but also those At Risk of Falls Improved Diagnosis and Read Coding of Dementia Read Coding Social Care Circumstances (Lives Alone, Care Package in place etc)

13 Primary Care and Community Integration GP Practice and CRT Liaison through Frailty DNs and CRT Inreach MDT meetings Information Sharing Joint Executive Level Information Sharing Policy WASPI ISP Frailty Sign Up from GPs Effective Read Coding at GP level should allow production of Frailty Registers - Software Supports Anticipatory Care for Patient / Client Locality Resource Planning at Locality Level

14 Whole Population Continued partnership working with colleagues in PHW, Community Regeneration and Leisure to ensure Physical Activity opportunities are available and accessible across the continuum Spreading the word Falls are not an inevitable part of the ageing process Positive Ageing Events Flu Campaigns

15 Any Questions? Diolch