Integrated Care Fund Challenge Session

1. Integrated Care Fund Challenge Session STAAR Pathway – Short Term Assessment and Acute Response

2. STAAR Pathway - Project Introduction • Overview of service provided The service is provided by staff rotating into a multi-disciplinary duty team. Referrals are received from the IAA service. The team will use the referral information, together with further information gathered from other sources to identify cases that could be suitable for a short term intervention. These cases should receive an assessment the same working day followed by an appropriate intervention or support. • Staff structure – additional resources allocated to the 3 Localities: • 3 x Social Workers Grade I • 3 x Occupational Therapists Band 6 • 2x Physiotherapists Band 7 and Band 5 – Stroke Pathways • 2 x Physiotherapy Technicians Band 4 – Stroke Pathways • 3 x Nurses Band 6 – Core Community Nursing

3. Funding arrangements

4. Project tie-in with ICF objectives PREVENTION • There is a need to focus on prevention and early intervention to make services sustainable into the future. • Section 15 of the Social Services and Well-being (Wales Act) 2014 places a duty on local authorities to provide or arrange the provision of preventative services which they consider will achieve the following purposes: a) Contributing towards preventing or delaying the development of people’s needs for care and support; b) Reducing the needs for care and support of people who have such needs. STAAR Pathway aims to prevent, delay or reduce people’s needs for care and support

5. Main types of Referrals • Individuals requiring Reablement as a preventive service • Individuals requiring early intervention such as OT / Physio assessment, equipment, advice on reducing risks, advice on adjustments to the way they carry out activities of daily living • Individuals requiring additional short term support or short term placement • Individuals requiring advice, signposting to 3rd sector services or telecare • Individuals requiring a SSWBA assessment of long term needs • Notably, very few referrals requiring a “crisis response” to prevent hospital admission

6. STAAR Pathway - Activity 2017/18 and 2018/19

7. Flow of Referrals (2017 & 2018)

8. STAAR Pathway - Activity

9. Where STAAR Screening Forms were triggered

10. Project Issues / Challenges • Not multi-disciplinary – mainly SW & OT • Consistency across the 3 CRTs – much higher proportion of STAAR cases progressing to long term in A&G • What kind of Intermediate Care service is STAAR? • Most closely matches the definition of “home-based” • Assessment and interventions to people at home to regain independence • However, the main difference is that the STAAR Pathway does not “hold” clients for a number of contacts over a 4 week period. No team ownership. • Service users referred on by STAAR to other desktops, quite frequently multiple desktops.

11. Key case studies Mr A has terminal cancer, stage 4, too weak to shower for last 3 weeks. Referral reviewed by SW / OT / Nurse, Joint visit by OT & SW. Physio referral made to review walking aids. OT prescribed equipment to aid washing and toileting and gave advice to reduce falls risks. SW arranged domiciliary care, 1 call per day but service declined on the basis of the charge of £31.50 p.w. Referral to Palliative care OT. How did patient benefit? Client received a response within one week of referralwhich prevented the development of his care needs Lessons learned? Earlier discussion about charging would have prevented needless commissioning of a service which was then declined

12. Key case studies Mr B referred by GP: Please could you assist this gentleman who live alone and his mobility is poor but is just about coping around the house. He cannot cook, he hasn't had a proper meal in many months and is feeling lethargic with bouts of confusion and he is struggling to take his medication as prescribed. Mr B reported to IAA that he is struggling with bathing and can’t afford heating or meals on wheels. IAA referred to Floating Support and to Telecare then triggered referral on to STAAR. Referral reviewed by MDT, follow up call by SW. Physio referral made to review walking aids. OT referral made to assist with bathing aids – declined appointment at present. Client declined SSWBA assessment. Client declined medication dispenser but accepted lifeline and safety sensors. Client declined benefits check. How did patient benefit? Client received a response within one day of referraland Telecare visit within one week which reduced risks at home. OT follow up took 3 months. Physio follow up completed? Lessons learned? Was Mr B given choice and control on what support he wanted? Numerous professionals involved in a simple referral. There were 7 attempted “hand offs” – no case coordination, poor customer experience?

13. Sustainability plan • ICF funding will be sought in order to continue development • Implications if the project were to cease would be that people requiring a short term intervention at home would not receive the most appropriate response promptly

14. Project development • STAAR needs further development – clear purpose and aims; protocols and standardisation of practice; activity and performance measures • Dedicated multi-disciplinary teams are key to improving case coordination and customer experience • Clear identity as a “home-based” intermediate care service within the overall Intermediate Care strategy • Need to develop a “crisis response” service and the appropriate assessment for accessing crisis response • TOCALS and STAAR could be the assessment services - using Comprehensive Geriatric Assessment tool to screen for Frailty

17. Conclusion • Further work on home-based and crisis-response intermediate care models is ongoing • The intermediate care pathway also needs development • Access hours to services are critical to effectiveness in terms of keeping people at home Debra Llewellyn, Modernisation Programme Manager