Supported by
JOINT STRATEGIC FRAMEWORK
FOR
INTERMEDIATE CARE SERVICES
IN
CONWY
2009 - 2011
G. Tabberer
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January 2010
Intermediate Care
CONTENTS
Page number
1.
2.
3.
4.
5.
6.
Executive Summary
Introduction
Background
Definition
Strategic Aims and Objectives
Local Need
6.1 Demography
6.2 Population Projections
7. Drivers for Change
8. Current Intermediate Care Service
8.1 The Health Precinct
8.2 Access Criteria
8.3 Colwyn Bay Community Hospital (CBCH)
8.4 Intermediate Care and Mental Health
8.5 General Practitioners
8.6 Social Services
8.7 Voluntary Organisations
9. Monitoring and Evaluation
9.1 Performance Indicators
10. Designing Integrated Services
10.1 Reablement and Rehabilitation
10.2 Communication
10.3 Clinical Governance
11. Key Issues
11.1 Overcoming organisational boundaries
11.2 Unified Assessment Process
11.3 Chronic Conditions Management
11.4 Expert Patient Programme and promoting Self Management
11.5 Telehealth and Telecare
11.6 Locality Working
11.7 Extra Care Housing
12. Training and Education
13. Future Developments
14. Summary of Work Plan – 2009-20011
15. Conclusion
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4
5
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9
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1.EXECUTIVE SUMMARY
This Strategy is the product of flourishing collaborative working with a range of professionals
within health and social care organisations, service users and carers within Conwy. It is a
combination of their recommendations, values and beliefs that have been amalgamated
within the document and will subsequently shape future developments of this community
model.
This Strategy aims to provide a broad scaffold for the further development of Intermediate
Care for adults within the County of Conwy. Realising this aim will call for a combination of
creative new ways of delivering existing services, which are receptive to patient need, and
the accessibility of new resources.
Implementation of the Strategy will, however, point towards the beginning of an ambitious
and challenging journey - and it should not be seen in isolation of other related initiatives or
as a short term solution.
This Strategy sets out work to date, and when adopted will lead to the delivery of a new
whole-system model of service delivery that rebalances in-hospital and out-of-hospital care
organised and focused within community settings.
Intermediate care is a now a model of excellence within Conwy - and is much more than a
team of health and social care professionals. This concept is further supported within the
report provided by Dr Chris Jones who notes in particular, that this model provides excellent
opportunities to develop community based services. It is this approach that will provide rapid
response, enablement, rehabilitation, admission avoidance and accelerated discharge
services for all adults in Conwy that need such provision.
The Health and social care communities of Conwy are committed to revolutionising the way
Intermediate Care is delivered, making a real difference to the quality of individual
experiences of health and social care provision.
Eleri Lloyd-Williams
Assistant Head of Primary Care Nursing
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January 2010
2. INTRODUCTION
In order to support the Regional Plans outlined within:
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Designed for North Wales
Community Services Framework
Making the Connections – delivering beyond boundaries
Fulfilled Lives and Supportive Communities
Supporting Communities – Carers Strategy
National Service Framework for Older People
A Strategic Framework for the development of Intermediate Care services in Conwy has
been developed, in response to the national drivers for change; this paper outlines the
developments which continue to build on good practice and push the boundaries of
Intermediate Care.
A key driver within “Designed for North Wales” is the recommendation to redesign health
care services, to better manage diseases in an increasing older population within primary
and community settings thus reducing the need for unnecessary secondary care admissions
and potential facilitating early discharge. However, the intermediate care services described
in this strategy are for adults and not specifically designed around the older person.
Designed to Improve Health and the Management of Chronic Conditions in Wales – an
integrated model and framework for action, advocates a proactive and integrated approach to
the management of chronic conditions which is planned with the involvement of key
stakeholders.
The document recognises the need to prevent or delay the onset of chronic conditions in the
first instance and the important contribution made by communities in achieving this goal. The
role of self care and self management of patients is also acknowledged. Intermediate care
services have a crucial role in ensuring effective, more sustainable services, supporting
those in need and indicates a way forward for managing the impact of chronic conditions
which is integrated and not fragmented.
In developing this strategy account has been taken of both national and local definitions of
intermediate care. The service developments proposed are also consistent with the
requirements of the Maintaining Independence Project, undertaken by Conwy Local Health
Board along with Health and Social Care partners, which highlights the necessity to avoid
prolonged hospital stays and reduce preventable admissions to acute inpatient, residential
and nursing home care.
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3. BACKGROUND
The NHS Plan for Wales includes undertakings to:
develop proposals for the provision of intermediate care facilities to meet the need for
short and long term care of people close to their homes whenever appropriate;

define the nature of intermediate care to ensure this is a positive option for care when
appropriate;

develop and implement proposals to strengthen intermediate care as part of the strategy
for older people.
The concept of Intermediate Care has been developing for many years and in Conwy, part of
the continued developments include innovative practice, forming partnerships between
Health, Social and Leisure services, underpinned by the re-design of the services provided
by Voluntary Organisations to provide appropriate support services for Intermediate Care.
4. DEFINITION
The Welsh Assembly defines Intermediate Care as follows:
Intermediate care describes a range of services providing time limited support to patients (up
to 6 weeks) which promote independence by avoiding unnecessary hospital admission or
admission to long term care, facilitates timely discharge from hospital and forms a bridge
between hospital, home, dependence and independence.
Intermediate care is provided on the basis of a comprehensive assessment resulting in a
structured individual care plan that involves active therapy, treatment, social work
intervention, or opportunity for recovery.
Intermediate care involves cross-professional working and agencies working in partnership,
with a single assessment framework, single service access criteria, single professional
records and shared protocols, although there is no current shared IT system in place.
Intermediate Care is not:
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Longer term rehabilitation
Rehabilitation that forms part of acute hospital care
Transitional care that does not involve active therapy or other interventions to
maximise dependence, i.e. for patients who are ready to leave acute in–patient care
and are simply waiting for longer term packages of care to be arranged, thereby
preventing active rehabilitation potential
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5. STRATEGIC AIMS AND OBJECTIVES
Strategic aims
 Promote independence and whenever possible enable people to remain in their own
homes
 Prevent unnecessary admission and readmission to hospital or long term care
 Facilitate timely discharge from hospital
 To facilitate timely discharge from short term care in residential/ Nursing Homes and
Extra Care Housing Short Term Care Flats.
 Provide specialist intermediate care assessment utilising the unified assessment
process and coordinating comprehensive assessments as required
 Maximise rehabilitation potential for people before making major life changing
decisions regarding their future care.
 To respond to carer breakdown and ensure the cared for person is made safe.
Strategic objectives
 Maximise the effectiveness and efficiency of the Conwy Intermediate Care Service
 Improve access and maximise capacity to ensure more people benefit from
intermediate care services including community mental health
 Link closely with community services i.e. Social Services and Health Locality Teams
and District Nursing and Community Mental Health Teams (Adult and Elderly).
 Develop the interface with other services e.g. community and specialist nursing and
short term locality based care teams
In line with “The Primary and Community Services Strategic Delivery Programme”
Intermediate Care provides excellent opportunities to develop community based services,
which can provide rapid response, enablement, rehabilitation, admission avoidance and
accelerated discharge services for all that need such provision.
The proposed system of care is predicated on the need for an expanded, integrated model of
highly organised community services that bridge the gap between primary and secondary
care such that holistic service provision is fully achieved, enabling:
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Care to be designed according to the holistic needs of the individual not just the
eradication of disease
Services delivered by a workforce where skilled generalists are highly valued and
roles are strengthened and where appropriate support from specialists is available.
Mature health and social care partnerships focused on joint accountability for
outcomes
Dependable community-based alternatives to hospital care to become valued as the
preferred mechanism for meeting needs.
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Locality Networks
Locality networks will be developed around natural communities as a key platform for local
service planning delivery. They will be built around Primary Care, Community and Social
Care teams, working together across agreed populations to deliver integrated core out-ofhospital services. They will foster and develop strong local ownership and leadership in the
development and delivery of services. Locality management will require a strong emphasis
within the new Health Boards.
Primary and Community Services Strategic Delivery Programme
6. LOCAL NEED
6.1 Demography
Gaining an understanding of the local population is a vital introduction to any assessment of
health and social care; therefore it is important to consider information regarding the
population structure, demography, mortality, morbidity, social and health influencing
behaviours of the population of North Wales, particularly Conwy.
6.2 Population Projections
At over 27% of the population, Conwy has the largest proportion of post-retirement age
residents in Wales, and the only areas with higher proportions of the elderly within their
population in England are well established retirement areas such as West Somerset.
Recently released estimates, which give population structures at small area levels, show that
the greatest concentrations of older people, in terms of both numbers and proportions of the
total population, are in the coastal settlements of Gele, Rhos on Sea, Llandudno (Craig-yDon, Penrhyn and Gogarth wards) and Deganwy.
Many of the areas of greatest population growth between 2001 and 2008 are concentrated
along the coast: Rhiw, Kinmel Bay, Abergele Pensarn, Towyn and Llysfaen all saw
population increases of over 5%. Surprisingly, the greatest increase in population was in the
rural ward of Betws-y-Coed (8.3%). Areas declining in population during this period are
mainly rural wards. Trefriw, Eglwysbach and Uwch Conwy all experienced a decrease in
population
Projections produced by the Statistical Directorate
of the Welsh Assembly Government in 2008
estimate annual growth rates of between 0.3%
and 0.7% per year for Conwy CB until 2026.
Current population trends are projected forward,
and show a range of differing population totals,
giving population growth levels of between 8,400
and 17,200 during the projections period.
Intermediate Care services have been developed
to cover the entire county of Conwy, providing equity of service for adults.
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January 2010
The total population of Conwy is projected to increase by 15,300 (or 13.7 per cent) by mid2031. This is below the average population growth (14.1 per cent) projected to be seen
across all Welsh local authorities
Conwy
The key results of the statistical projections (WAG 2007) for the period to 2031 conclude that
by 2031 in Wales:
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The population is projected to increase by 11 per cent to 3.3million
Children are expected to represent a little over 17 per cent of the population, and
pensioners over 24 per cent.
The number of children is projected to increase by under one per cent (4,000), the
number of pensioners is projected to increase by around 31 per cent (188,000), and the
number of people of working age is projected to increase by 8 per cent (138,000)
The population of Wales will become gradually older with the median age of the
population rising from 40.6 years in 2006 to 44.3 years in 2031.
7. DRIVERS FOR CHANGE
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Primary and Community Services Strategic Delivery Programme. National Advisory
Board. NAB(01)02
The National Service Framework (NSF) for Older people in Wales
Conwy Health Social Care & Wellbeing Strategy 2008-2011
Wanless Report
Strategy for Older People in Wales
Designed for Life
A Strategy for Social Services in Wales over the Next Decade: Fulfilled Lives
The Annual Operating Framework (AOF)
The Communities Service Framework 2008-2011
“Climbing Higher” – creating an active Wales
Designed to Improve the Health and Management of Chronic Conditions in Wales: An
integrated model and framework for action (Welsh Assembly Government March 2007)
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8. CURRENT INTERMEDIATE CARE SERVICES
Conwy Community Intermediate Care Service Team (C.I.C.S.)
8.1 The Health Precinct
The aspirations of the Health Precinct are directed by the Wanless Report and the Climbing
Higher Strategy, both of which:
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recognise the invaluable contribution all forms of physical exercise make to the
prevention and management of a wide range of chronic diseases
recognise the need for new and innovative approaches to address the issues of
chronic ill health and rehabilitation
recommend a partnership approach to finding effective solutions
identify the need for strong evaluation protocols to be applied to potential solutions.
The “Health Precinct” is a joint partnership between Age Concern, North Wales NHS Trust
and Conwy County Borough Council.
The project is part of an exciting development programme at Colwyn Leisure Centre which
complements and extends the wide range of community activities and programmes taking
place at the Eirias Park complex.
This collaboration supports a wide range of local residents to move seamlessly from
medically supported therapy to community based physical activity. There is also an
opportunity for the very important social element to be integrated into the delivery of
programmes.
Increasing physical activity is an NSF (National Service Framework for Older people) target.
By providing a base for the CICS Team within the Health Precinct, fosters a climate of multiagency and cross-provider integration and provides specific tailored exercise to improve
fitness and health across all ages and abilities. Networking between Conwy Local Authority
and North Wales NHS Trust can only forge improved standards of health, social care and
wellbeing, to facilitate direct and immediate access to the specialist within the CICS Team.
Designed for Life promotes a refocus of health improvement and prevention of ill health and
having health care delivered in a leisure centre provides a change in culture by concentrating
the mind on regaining health, rather than on illness in a hospital or clinic setting.
The CICS Team provides a multi-disciplinary approach to care, with membership across
several professional agencies. The service encompasses rapid response, rehabilitation,
enabling support and provides an individual treatment plan for patients with specific
outcomes. The treatment plan may include Physiotherapy, Occupational Therapy, and
Nursing to ensure all identified healthy living options are addressed. The position of Social
Workers on the Team also ensures that social aspects are assessed and a full multidisciplinary assessment will always be undertaken. The Care Coordinator in the Team
ensures there is management of the support workers and regular feedback to the
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January 2010
professionals in the team re progress with clients. The Team provides a totally holistic
approach encompassing environmental, physical, functional and social aspects of an
individual’s expectation of life quality setting achievable goals for each individual. The team
also has a Community Psychiatric Nurse to address any mental health issues and forge
appropriate links with the Mental Health and Learning Disabilities Division.
The Wanless Report and Designed for Life both compliment and support the “Climbing
Higher” strategy to increase the number of people taking part in sport and physical activity.
“Climbing Higher” – creating an active Wales
A strategic action plan focuses on ensuring that we all build physical activity into our daily
routines. It forms part of Our Healthy Future, the Welsh Assembly Government’s strategic
approach to improve the quality and length of life.
‘Creating an Active Wales’ recognises the importance of having a built environment that
supports people to be active and having access to green spaces.
The plan also acknowledges the need to provide support for people to become more
physically active through targeted programmes that support behavioural change. A particular
emphasis will be placed on increasing physical activity in the sedentary population
Strategic themes include:
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Active environments
Active adults
Sport for all
In addition, actions have been developed to support the underpinning themes of:
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National leadership
Local delivery
Communication
Workforce development
Wider partnerships
Developing the evidence base
The Health Precinct provides an environment conducive to people who are unfit and
uncomfortable in a sports centre environment by providing awareness that low level physical
ability is not a barrier and does not prevent them from accessing these facilities. Being
aware that people with similar abilities are using the amenities has the potential to motivate
them to take the first step in regaining their fitness thus improving their health.
People who currently receive a service from the CICS Team may suffer from Neurological
Disease, Chronic Heart Disease, Diabetes, Chronic Obstructive Pulmonary Disease and may
have frailty of old age, falls, balance and co-ordination difficulties and may potentially suffer
from broken limbs. It has been proven that regular exercise (either supervised or
unsupervised) has a positive physical, emotional and psycho-social benefit. The long term
cost to both health and social services which results from such health problems can be
reduced by schemes that deliver active intervention in the leisure arena.
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The Team has rehabilitation assistants and support workers, who support individuals at
home with supervision from the Team’s specialists. They work in an enabling and
empowering way and play an important role in an individual’s rehabilitation. They provide
assistance with activities of daily living and other tasks to enable patients to live in their home
environment and aim to improve confidence and restore function to ensure each person
achieves their optimum potential.
The Older People’s Strategy for Wales aims to provide more choice for the older person to
enable continued independence and autonomy. The Health Precinct offers a variety of
programmes, from walks on level ground in beautiful surroundings to high tech equipment in
the gym and participation from the CICS Team to enhance the expertise available.
PALS (Positive Active Living Saturdays) is a programme for over 50’s who do not want to
compete with younger people or feel self conscious among extremely fit and active gym
users. The activities offered are varied and include tai-chi, aqua aerobics, line and ballroom
dancing, badminton and the use of health and fitness suites. It also importantly provides an
opportunity for social interaction. The service complements other activities and initiatives
within the centre, such as the g.p. referral scheme and the evergreens programme, all of
which are open to referrals from the CICS Team.
The Health Precinct raises awareness that adapted equipment is available to cater for the
needs of people with a physical disability or sensory impairment. In the past people with a
disability may have been reluctant to make use of a gym due to the complex machinery and
uncertainty of what exercises they could safely manage. Having a multi-disciplinary/agency
team reassures them that a specific programme of exercise is safe and with new technology,
closer monitoring of individuals is possible.
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January 2010
8.2 Access Criteria
C.I.C.S.
Conwy Intermediate Care Service
Access Criteria
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* The client must be over 18 years old.
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* Resident in County of Conwy
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* The client agrees to Intermediate Care intervention
*Clients must meet the above criteria plus at least one of the following
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Has potential to respond to short term intervention (maximum of 6 weeks)
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The client has a condition which can be safely managed in their place of residence
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Facilitate early discharge or support admission avoidance as part of chronic condition
management
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Carer breakdown
Process for referral:
The office hours are Monday – Friday 9.00 - 5.00pm
All clients referred due to a fall will be assessed
Referrals can be made by all staff disciplines within health and social care.
Referrals marked ‘URGENT’ will be responded to within 2 hours of receipt
Referrals must be made using the Unified Assessment documentation and faxed to:
01492 535354
Advice is available from a professional team member every afternoon Monday – Friday
between the hours of 2pm & 4pm on 01492 535354 or 01745 448337/6.
Conwy Intermediate Care Service
The Health Precinct,
Colwyn Bay Leisure Centre
Eirias Park
Colwyn Bay
LL29 7SP
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January 2010
8.3 Colwyn Bay Community Hospital (CBCH)
The local community hospital has 42 beds, for GP, Care of the Elderly (COTE) and
Intermediate Care patients. The CICS team has access to COTE beds as appropriate with
medical cover provided by a Consultant with specialist interest in intermediate care.
With effect from January 2007, appropriate patients from the community (Conwy County)
could be directly admitted by the CICS team or District Nurses to allocated Intermediate Care
beds in Colwyn Bay Community Hospital (CBH), however, beds are available for those
patients who require Intermediate Care intervention and are not designated as ‘Intermediate
Care beds’.
8.4 Intermediate Care and Mental Health
There is recognition that there are considerable opportunities for general physical
intermediate care services to work more closely with mental health community services.
With the recruitment of a CPN (Community Psychiatric Nurse), patients who would have not
been accepted for physical or indeed mental health needs, are now identified. However,
more resources will need to be available to enhance the current capacity and provide further
opportunity for community mental health and I.C. teams to collaborate more effectively.
8.5 General Practitioners
Evidence shows those practitioners accessing I.C. in Conwy have a lower referral rate into
A&E departments and recent surveys state practitioners are using I.C. services more, with
easy access following the single point of referral. It was also found that IC services are
considered before G.Ps refer patients to A&E, which was a common practice before the
availability of a whole Conwy I.C. service.
8.6 Social Services
There are strong links with Adult Social Services with the Principal Practitioner managing the
Team of Social Workers in CICS and Social Workers in Ysbyty Glan Clwyd so strengthening
the links with the acute hospital. The Social Workers in the Team link with each Locality
Team in order to develop the links and gain knowledge of local resources.
The Operational Manager for Commissioning manages the Social Work Teams Older People
and Hospitals and attends the Strategic Group. The Operational Manager Older People
Provider Unit manages the Care Coordinator and attends the Operational Group.
The Customer Care Team liaise closely with CICS for new referrals and enquiries ensuring
there is a seamless service.
8.7 Voluntary Organisations
Intermediate care services, as the interface between community services and secondary
care, are crucial to relieving the burden on acute care and ensuring people are facilitated to
maintain their independence and as such, contribute significantly to achieving the aims of the
Community Services Framework. It is also an area where the voluntary sector has a lot to
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offer and for this reason Intermediate Care has been identified as an ideal arena to explore
the ideas in the paper “Public and Voluntary Sector Engagement in the Planning and Delivery
of Services”.
Conwy Community CIC Start Project Group will initiate a pilot within the County of Conwy
over a 12 month period to work in partnership with Conwy Intermediate Care Service Team
by supporting their clients (aged 18 year and over) to achieve their optimum level of
independence.
The project will include a package of services which will be available to meet the clients’
needs, including chronic condition(s), for a maximum period of 12 weeks.
9. MONITORING AND EVALUATION
A vital element is to ensure the team is effective in delivering improvements in peoples’
health and social care. This is achieved by implementing a performance framework and
setting standards against which the service can be measured.
9.1 Performance Indicators
The purpose of the indicators is to provide a high level summary of Intermediate Care
performance, reflecting as fully as possible the functions of the service and range of various
disciplines involved in the patients care. In particular, the indicators reflect the priorities that
have been set for the multi-agency team and measure progress against key standards and
targets for both Health and Social Services. Consequently the indicators are constantly
being developed and improved as new sources of information become available. The
indicators reflect key service standards as defined in the National Service Frameworks and
include a broader range of indicators, which reflect the quality of treatment that patients
receive and their outcomes.
10. DESIGNING INTEGRATED SERVICES
The task is not simply to create new services, but to:
 strengthen existing services in the community;
 relocate services to the community;
 link and streamline services across the community;
 decommission services no longer meeting needs
 ensure the resultant services are effective and meet all value for money
challenges.
Re modelling of services has opened up opportunities to create further partnership working
with Leisure services, by co-locating the CICS Team with the Health Precinct. The innovative
structure will continue to develop, creating true partnership working to benefit the residents of
Conwy. The team has a direct referral pathway into leisure services and “exercise on
prescription” which has far reaching implications for patients who are known to be frequent
fallers. These patients are offered a specific programme of exercise which is safe and with
new technology, individuals are closely monitored.
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Reablement and Rehabilitation
Reablement/Rehabilitation IC services provide a multi-disciplinary service responding to
referrals from Social Services, therapy and nursing services (community and acute based),
GPs and other professionals.
10.1
Communication
 A single point of referral has been established, creating effective communication
between the referrer and the CICS team.
 The partnership between health and leisure services continues to develop, providing
direct access into the exercise on prescription programme for CICS patients.
 The Intermediate Care and Secondary Care Partnership forum has been established,
creating clearer pathways of care.
 An informal partnership is currently underway in terms of a pilot with WAST and Out of
Hours service (Morfadoc), providing communicative links for elderly patients who have
fallen and are not referred to any service. The pilot will be evaluated after the first
month.
 There is also a falls pathway being developed in conjunction with Dr Gerallt Owen
(North Wales NHS Trust - Consultant Physician-COTE) and Leisure Services.
 There are links to the Social Care and Health Locality Teams.
 Voluntary Organisations are currently working with Intermediate Care to provide a
consortium of services to provide CICS patients with twelve weeks support during or
after their time with CICS.
 Communication has been established with secondary care in terms of I.V. antibiotics,
the possibility of home delivery and the work surrounding the needs assessment.
10.2
Clinical Governance and Intermediate Care
Clinical Governance underpins the process of maintaining and improving the quality of
services for people receiving Intermediate Care. The current and new developments promote
a culture of reflection, evaluation and improvement, which the Directorate’s framework
supports focusing on patient safety and new ways of working
10.3
11. Key Issues
11.1 Overcoming organisational boundaries
Organisational boundaries are not allowed to obstruct access to the assessment and
management pathways that underpin intermediate care. A cohesive system of governance is
in place and ensures effective co-ordination and accountability for all involved in intermediate
care.
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January 2010
11.2. Unified Assessment Process
The use of the Unified Assessment Process offers a tool for facilitating early involvement of
appropriate assessors. Intermediate Care is provided on the basis of a comprehensive
assessment, (as defined within the Unified Assessment & Care Management system),
resulting in a structured individual care plan that involves active therapy, treatment or
opportunity for recovery. The initial assessment identifies the appropriate clinician with
managerial responsibility and the most appropriate care co-ordinator; have a planned
outcome of maximising independence and typically enabling patient/users to resume living at
home.
11.3. Chronic Conditions Management
Chronic conditions are placing an ever increasing demand on health and social care services
in Wales due to the growing trends in the prevalence of chronic conditions and the
association with an ageing society. In fact chronic conditions are currently affecting
unplanned hospital admissions and length of stay with delayed discharge. This not just only
impacts on the services but more notably on the patient’s quality of life.
In Wales it is estimated that by 2014 there will be a 12% increase in adults with at least one
chronic condition and a 20% increase in those over 65 with a chronic condition (A Profile of
Long Term Conditions in Wales, Welsh Assembly Government 2005). What is interesting
however is that Conwy has the highest over 65 population in Wales which is inherently
associated with an increase in chronic conditions. It is essential therefore that chronic
conditions are effectively managed with a focus on prevention, early diagnosis, treatment,
maintaining independence, improving quality of life and bringing services closer to patient’s
homes and communities. In light of this a local three years Chronic Conditions Management
(CCM) Action Plan for Service Improvement has been developed in order to capture all these
elements. This Service Improvement Plan is currently being implemented and monitored, in
order to deliver more sustainable integrated community services for the long term in line with
the needs of our local population.
The Intermediate Care Service has a key role within this and is proactive in ensuring effective
chronic condition management by utilising a multi-disciplinary, whole systems approach to
care, with the patient at the centre. The service is now well established across all Conwy
localities and is responsive to the needs of the patient, family and carers creating a climate of
support and encouragement for the individual to regain as much independence as possible
within the home, to prevent admission to and to aid early discharge from hospital. The
improvement in health and well-being is facilitated by health promotion thus preventing a
worsening of chronic conditions through rehabilitation, education and advice. The
Intermediate Care intervention also improves consistency in the development of the chronic
disease pathways across Conwy
11.4 Expert Patient Programme and promoting Self Management
Helping people towards self management within Conwy is a major component of the care of
individuals with chronic conditions and one which the Intermediate Care Service recognises
as vital. Empowering patients and the promotion of self-care is being emphasised through
national initiatives, such as NHS Direct and NHS Online own care. ‘The Expert Patient: A
New Approach to Chronic Disease Management for the 21st Century’ was published in
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January 2010
September 2001 by the Department of Health. It sets out how the NHS will empower those
people living with chronic long-term medical conditions to become key decision makers in
their own care.
Therefore the Expert Patient Programme (EPP) lay led self-management course to help
people maintain their health and improve their quality of life has been operational in Conwy
since 2005 and during 2009/10 six programmes will be run to include a 'Looking after me
course' for carers and a course for individuals with dual sensory loss (hard to reach group).
Within the Intermediate Care Service self management is high on the agenda and the service
continues to promote the EPP and other self management initiatives to their client group with
direct referral as appropriate.
11.5. Telehealth/Telecare
The use of new and emerging assistive technology such as Telecare and Telehealth has an
important role in bringing services and information closer to peoples homes and communities
across Conwy, with particularly significance in the rural areas and can support and enhance
citizen’s lives in diverse areas such as: medical care, independent living, self management,
quality of life and assisted care. Home-care monitoring equipment within the home provides
considerable opportunities to support patients health condition(s) and reduce the risks of
unnecessary hospital care and assist early supported discharge. It allows for an early
intervention approach to care with increased positive outcomes for the patient The
Intermediate Care Service is currently part of a Telehealth pilot within Conwy and all received
referrals are screened for the Telehealth intervention.
11.6 Locality Working.
The development of Social Care and Health Locality Teams has improved multidisciplinary
working and the Intermediate Care Team needs to work closely with these teams. The
relocation of the Support Workers into the Locality Social Services Care Teams should
ensure greater efficiency and strengthen the links with the localities and increase use of local
resources.
11.7 Extra Care Housing
There Extra Care Housing schemes being developed across Conwy for older people two will
be operational in 2009. This is another opportunity for independent living and the
Intermediate Care Team will have a vital role to play in ensuring people maintain their
independence. The development of short term flats in the Llanrwst scheme Hafan Gwydir will
provide an alternative setting for people to have intensive support from the Intermediate Care
Team to assist people in regaining their independence.
G. Tabberer
- 17 -
January 2010
12. TRAINING AND EDUCATION
“The transition to a new pattern of services will require a restructuring of the workforce, new
forms of organisation, changes in practice and improved efficiency.”
Ref: “Designed for Life”
Innovation in employment practices, skills, training, staff location to support reconfiguration
and service improvement will require action and support from all levels.
Intermediate Care will continue to extend professional roles by becoming a key player in
delivery of intravenous (I.V) antibiotics service to be delivered to the appropriate patients
within their home environment. Training and education for I.C. nurses will be required.
Key points
 Home administration of antibiotics has taken place in the UK since the 1980’s and is
suitable for a wide range of conditions.
 To deliver home antibiotics, a comprehensive treatment plan must be in place.
 Administration of antibiotics at home can be cost-effective, safe and patient friendly.
Ref: British Journal of Home Healthcare Vol 4 No 3
Joint training between Health Social Services and Leisure will drive forward the partnership
working practice within the Health Precinct to provide services requiring the skills of Health,
Social and Leisure services. Action learning sets will be available enabling participants the
opportunity to learn from each other, engage in shared learning and enhance the
opportunities given to learn more about each other’s organisational practices.
The commissioning of joint education and training, professional codes of practice, workforce
planning and the addressing of training and team working issues (including the crossing of
professional, departmental and organisational boundaries, are key areas for development by
underpinning future workforce development strategy in a proactive and informed, rather than
reactive.
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Ensuring staff are supported to work at their optimum level of expertise.
Provide joint training to develop skills and competencies to meet new service
demands and policy initiatives.
Ensure annual appraisals are undertaken.
Adhere to the requirements of the clinical governance agenda.
Strengthen links with localities
Development of generic support workers
These are noted as crucial areas in the recent review ‘Beyond Boundaries’ led by Sir Jeremy
Beecham.
G. Tabberer
- 18 -
January 2010
13. FUTURE DEVELOPMENTS
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The existing service operates from Monday to Friday from 9am -5pm only, with no
evening or weekend service available other than evening and weekend cover from
support workers
A need for extra care housing
A greater focus on pharmacy and medicines management
A need for community support rehabilitation/reablement IC services
Gaps must be filled and connections made
Intermediate care services are, in essence, the interface between the community services
and secondary care. They are services that many providers have an input to but often are
not co-ordinated effectively. They will include a range of services, which may be provided in
non-acute local hospitals, resource centres, or in people’s own homes. These services will be
crucial to relieving the burden on acute care and to ensuring that people receive the best
possible treatment close to home.
The aim for intermediate care should be to make the maximum use of the total resource
available across all sectors, to support independence, to prevent admission to an acute
hospital setting, or to facilitate home discharge and return to independent living following a
period of acute care. They need to be better used.
Overall in the design and management of services, the governing philosophy must be to see
individual services as part of a greater whole, organised around user needs. Although
services will have to match local circumstances, for example rural or urban settings, there
should be common criteria and quality standards at all times.
G. Tabberer
- 19 -
January 2010
14. SUMMARY OF WORK PLAN – 2009-20011
In order to develop Intermediate Care in Conwy, pathways and protocols between services
and agencies will work together. To facilitate this, there will be a need to:

Work closely with hospital Consultants and General Practitioners to develop an
integrated model of Intermediate care.
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Continue to develop joint working practice between the C.I.C.S. Team and District
Nursing
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Develop a 7 day a week service
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Develop community equipment services in line with the integration project to offer
further opportunities for I.C.
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Further develop referrals to telecare and telehealth services.
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Strengthen links with Social Care and Health Localities.

Relocate the Support Workers into the Short Term Care Enabling Teams which will be
rolled out to cover the whole of Conwy in line with Intermediate Care requirements

Continue to develop specialised mental health expertise within I.C. services.
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Ensure linkage between Extra Care housing and Intermediate Care services.

Identify future investment opportunities for I.C.

Develop links with Pharmacy services.
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Joint working protocols with DN and therapy service to provide assessment in outlying areas

Collaborate on working protocols with Morfa Doc and out of hours nursing

Collaborate on working protocols with specialist services e.g. chronic disease
management, COPD (Chronic Obstructive Pulmonary Disease) clinics, falls services,
out-patient services
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Develop joint working protocols with Denbighshire Response and Rehabilitation
Service (RARS)
G. Tabberer
- 20 -
January 2010

Develop the falls pathway with the Welsh Ambulance Services Trust, Intermediate
Care, falls clinics and Leisure Services
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Develop and evaluate the ‘CIC Start’ project with the Voluntary Organisations

Take forward opportunities for administering I.V. antibiotics service at home
15. CONCLUSION
Intermediate care services aspire to facilitate maximum independence for people and to
prevent the need for long term or continuing health and social care. Conwy has made great
progress and is now leading the way in innovative working practices across Wales. The
continuing development of intermediate care services will make a real difference in alleviating
pressures on hospital, health and social care systems preventing many people from being
placed in inappropriate care settings.
The Interface between Hospital and Community is crucial for intermediate care services. All
services at all times should be geared for ensuring that people are not inappropriately placed
or delayed unnecessarily. Clinical and management decisions in one part of the system can
have a dramatic impact on other parts of the system, and clinicians and managers must
ensure there is close and continuing liaison and joint working across primary and community
services, and acute services.
The multi disciplinary ADT (Assessment and Discharge Transfer) Team in Ysbyty Glan
Clwyd has a key role in ensuring people are not unnecessarily admitted to acute hospital,
and where they are, they move as smoothly and appropriately as possible between hospital
and community.
People do not have needs only on Monday to Friday between 9.00am and 5.00pm. Incidents
in the home leading to loss of independence can happen at any time, and there must be a
range of services available at all times to respond rapidly with appropriate services. These
services must aim to prevent hospital admission and enable the older person to return home
as soon as possible.
The full range of intermediate care services must therefore be available seven days a week,
with sufficient emergency response available during the night. Rapid response services are
part of an overall intermediate care service with strong links between care/nursing homes,
hospitals and other services.
Therapy support, is paramount to ensure those therapists who are working within Conwy are
working in as flexible a way as possible, across organisational boundaries to prevent
hospitalisation and enable people to remain as independent as possible in their own homes.
The progress of I.C. services in Conwy over the last few years must not be
underestimated. Recognition in the form of the Excellence Wales Award has
ensured the profile of the CICS Team is acknowledged. Building on success will be
G. Tabberer
- 21 January 2010
the watchword for the future