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Integrated Care Fund Challenge Session

This evidence-based project aims to reduce injurious falls in older adults and maintain their independence, while reducing the need for formal care and risk of hospital admission. It establishes clinical exercise pathways, integrates with the National Exercise Referral Scheme, and develops outreach specialist exercise programs for older, frailer adults.

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Integrated Care Fund Challenge Session

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  1. Integrated Care Fund Challenge Session Health and Activity Coordinator for Specialist Populations in Carmarthenshire

  2. Project Introduction This is an evidence base project in relation to reducing injurious falls in older adults and its impact on maintaining independence, reducing the need for formal commissioned care and risk of hospital admission: •  Establish evidence based clinical exercise pathways for older adults and frailer older adults County wide • Compliment and integrate with the National Exercise Referral Scheme (NERS) in order to develop a robust exercise based exercise continuum addressing key health agendas • Liaise with strategic partners within the Health Board to ensure safe exercise pathways for clinical populations (e.g. falls, stroke, heart failure, COPD and Osteoporosis) • Develop and deliver an outreach specialist exercise programme for older, frailer adults •  Identify opportunities for development, pilot programmes in order to extend and increase exercise opportunities to ‘hard to reach’ groups.

  3. Funding arrangements

  4. Project tie-in with ICF objectives Citizens get the right care and support, as early as possible • The project accepts referrals directly from GP, specialist physiotherapy and the rapid access frailty service to ensure that referrals for frail individuals access the service as soon as possible. Citizens get the help they need be independent • This is an evidence base project in relation to reducing injurious falls in older adults and its impact on maintaining independence, reducing the need for formal commissioned care and risk of hospital admission.

  5. Project key achievements • Performance • Key achievements and outcomes • Activity • Performance indicators • Value for money / return on investment

  6. Project key achievements Outreach – L4 Sessions Delivered Countywide 18-19

  7. Project key achievements- Outreach Visits Countywide 18-19

  8. Project key achievements - Falls Referrals completed 16 weeks.

  9. Project key achievements- OutcomesEQ5D & VAS Results January 17 – December 17

  10. Project key achievements Care Home Pilot Sessions Delivered January 18 – December 18

  11. Key achievements and outcomes Identify opportunities for development, pilot programmes in order to extend and increase exercise opportunities to ‘hard to reach’ groups. • 15 Senior Care Staff, Domiciliary Care Workers and Community Health Care Support workers are now qualified to deliver Falls Prevention strength & Balances sessions in their place of work (physiotherapy, Residential care & Assisted Living Care). • With the delivery, mentoring and ongoing support from Health & Activity Coordinator the Leaders will gain in confidence and have the skills to sustain sessions long term building resilience against further injurious falls and support independence..

  12. Key achievements and outcomes • Two sessions per week of Integrated Chair Based and Otago (Falls prevention) structured exercise sessions are being delivered at Llys y Brynresidential care home in Llanelliand Ty Dyffryn Assisted Living complex in Ammanford. • February/March 2019 – Sessions to start at CartrefCynnes, Carmarthen. • April/May 2019 – Sessions to start at AwelTywi, Llandeilo

  13. Key case study • Mrs R has attended 33 sessions to date and early assessments recorded. • Sit to stand over 30 seconds – Mrs R recorded 4 sit to stands at week 1 with support of a rollator - • 5 months - 9 sit to stands recorded with NO SUPPORT which shows improvement in her lower limb strength. • Timed up and go – at week 1 - 32 seconds with a rollator • 5 months – 23 seconds with NO SUPPORT- Improvement of motor ability and dynamic balance as well as increase in confidence. • EQ5D - Mrs R has recorded an Improvement in her walking. • Reduction in her pain. • Improvement in her overall health 40% - 70% • FES-1 (Fear of Falling) – Week 1 26 • 5 months 14

  14. Case Study - Quotes • I really enjoy coming to the sessions • I have increased my confidence. • Everything you do is helping me. • I feel happier. • Due to her increase in confidence Mrs R has recently been on a trip to London with her family

  15. Sustainability plan • How will the project be sustained in the future? Will ICF funding be sought in future or will it become self-funding / core-funded? What are the implications if the project were to cease (ie is there an exit strategy)? Please use this opportunity to demonstrate the value for money your project has/will achieve: If this post was not in existence, none of the outreach delivery would have been established and future outreach provision would be under serious threat. We are as an authority looking to overcome rural deprivation, isolation and foster community resilience. The innovation, networking and specialism that comes with this post is an extremely rare commodity. This post delivers on all of the above, playing a fundamental role in the networking, knowledge and drive required to ensure sustainable physical activity provision and social support for our frailer older adults. If further funding was not forthcoming via ICF of Core Funding, the would have to be placed on the redeployment register.

  16. Project Development Further development in the project would be to explore, expand and sustain work with: • Integrated working with Falls & Frailty Team. • Integrated working with Carmarthenshire County Council Falls Prevention & Carmarthenshire is Kind taskforce groups. • Integrated working with Care & Repair. • Integrated working with HDUHB Local Falls Taskforce group. – Falls Brief Intervention Training. • National Prudent Falls Prevention Workshop

  17. Conclusion • Potential cost saving of £35,000 per referral taking part in the Falls prevention program. • Reduction in hospital admissions/physiotherapy services and reduced pressure on social care services due to injurious falls e.g. fracture of neck of femur through promotion of functional gain. • Reduced ‘fear of falling’ through promotion of functional gain and confidence building. • Increased independence, wellbeing and self management of condition resulting in a reduction in the requirement of care packages or number of care hours required. • Increased/Maintenance of functional gains & independence of participants and Residential/Intermediate venues following physiotherapy rehabilitation programmes. • Where applicable, decreased number of Lifeline / Telecare ‘Client Fallen’ reports • Decreased Welsh Ambulance Services NHS Trust ‘999’ calls to fallers.

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