Prevention stage 2

Prevention Stage 2: Maintain independence through provision of targeted support that prevents the need for people to be admitted to hospital or long-term residential care, or supports timely discharge

Objective Timeframe Strategic priority Population groups Links to Overarching Recs/ Areas for Improvement Links to National Outcomes Implementation Plan/s
2.1 Implement consistent, multi-disciplinary approach to assessment and care planning across the region, supported by WCCIS, to ensure a focus on individual outcomes and preserving independence Medium term IAA and prevention/ Service Integration and Pooled Funds/ WCCIS All OR1;
OR6		 N1; N2; N3; N4; N5; N6; N7; N8; N9; N10; N18; N22 Implementation Plan under development
2.2 Develop integrated community care model through locality-based community hubs, providing proactive low level care, step-up facilities and joined up management of chronic conditions, reducing admissions to hospital or long term care and supported by pooled fund arrangements Medium term IAA and prevention/ Service Integration and Pooled Funds All OR3;
OR4;
OR6;
OR7;
OR8		 N1; N2; N3; N5; N7; N9; N10; N12; N24 Service Integration and Pooled Funds Programme Plan
2.3 Ensure multi-agency community-based support and step-down facilities are available to facilitate timely discharge Medium term IAA and prevention All OR3;
OR4;
OR6;
OR7		 N1; N5; N6; N7; N8; N9 2018/19 ICF Regional Investment Plan under development
2.4 Deliver integrated training and development programme to support improved practice in targeted care and services Medium term Workforce Development All OR3;
OR7		 All Regional Social Care Wales Workforce Development Programme (SCWWDP) – link to follow
2.5 Review arrangements for Integrated Community Equipment Stores and implement regional model, including consideration of pooled fund arrangements Short term Service Integration and Pooled Funds All OR3;
OR4;
OR7;
OR8		 N7; N8; N9; N24 Review currently in progress
2.6 Review service contracts and consider single regional contract with pooled fund arrangements for Integrated Community Equipment Stores Short term Integrated commissioning/ Service Integration and Pooled Funds All OR1;
OR6;
OR7;
OR8		 N7; N9; N22; N24 Review currently in progress
2.7 Implement Care and Support At Home Strategy in West Wales Medium term Integrated Commissioning/ Service Integration and Pooled Funds/ Workforce All adults OR1;
OR6;
OR7;
OR8		 N3; N4; N5; N6; N7; N8; N9; N10; N24 Care and Support at Home in Wales Five Year Strategic Plan
2.8 Ensure adults and children with autism and a learning disability or mental health problem receive appropriate, coordinated, targeted care and support through the development and implementation of a regional Integrated Autism Service Short term IAA and prevention Autism OR1;
OR3;
OR4;
OR6;
OR7		 N1; N2; N3; N4; N5; N6; N7; N8; N9; N10; N13; N14; N17; N18 West Wales Integrated Autism Project Proposal
2.9 Ensure appropriate carer involvement in assessment process and that carers are offered their own assessment Short term IAA and prevention Carers Carers OR1;
OR3;
OR4;
OR6		 N1; N2; N3; N4; N5; N6; N7; N8; N9; N11; N12; N18 West Wales Carers Delivery plan
2.10 Deliver and consolidate regional arrangements for the Integrated Family Support Service (IFSS), working in partnership with other services to maximise opportunities for children and young people to remain or be rehabilitated to their families. Arrangements to include pooled funding as required by the Social Services and Well-being (Wales) Act Short term Service Integration and Pooled Funds Children and Young People OR1;
OR3;
OR5;
OR6;
OR7;
OR8		 N1; N2; N3; N4; N5; N6; N7; N8; N9; N10; N11; N12; N18; N24 Integrated Family Support Service Mid and West Wales
In the Mid and West Wales Region there are 4 Integrated Family Support Teams based in Carmarthenshire, Ceredigion, Pembrokeshire and Powys. Mid and West Wales IFSS Collaborative Agreement being reviewed – to follow.
2.11 Ensure targeted support meets the needs of children and young people with mental health problems through the Together for Mental Health Strategy Medium term Transforming Mental Health Services Children and Young people OR1;
OR3;
OR5;
OR7;
OR8		 N1; N2; N3; N4; N5; N6; N7; N8; N9; N10; N13; N14; N16; N22 Transforming Mental Health Implementation Plan
Regional arrangements in development – documentation to follow
2.12 Ensure appropriate, integrated step-up models of care are available when needed for people with a Learning Disability, drawing on the regional Model of Care and Support Medium term Transforming LD services Learning Disabilities OR3;
OR6;
OR7		 N5; N7; N8; N9; N10 2018/19 ICF Regional Investment Plan Regional strategy under development
2.13 Reduce residential packages for people with learning disability in favour of supported living schemes and improve access to opportunities within the wider community Medium term Transforming LD services Learning Disabilities OR1;
OR3;
OR6;
OR7		 N5; N7; N8; N9 Strategy under development
2.14 Ensure targeted support meets the needs of people with mental health problems through the Together for Mental Health Strategy Medium term Transforming Mental Health Services Mental Health OR1;
OR3;
OR7;
OR8		 N1; N2; N3; N4; N5; N6; N7; N8; N13; N14; N22 Transforming Mental Health Implementation Plan
2.15 Establish community Mental Health Services across the region, incorporating 24/7 Community Mental Health Centres and Central Assessment and Treatment Units Medium term Transforming Mental Health Services Mental Health OR1;
OR3;
OR7;
OR8		 N1; N2; N3; N4; N5; N6; N7; N8; N9; N13; N14; N22 Transforming Mental Health Implementation Plan
2.16 Ensure targeted care and support services meet the needs of people with dementia through delivery of the Regional Dementia Strategy Medium term IAA and prevention/ Service Integration and Pooled Funds Older People OR1;
OR3;
OR7;
OR8		 N1; N2; N3; N4; N5; N6; N7; N8; N9; N10; N12 Dementia Action Plan for Wales 2018-2022
Regional strategy under development
2.17 Ensure assessment and care planning approach identifies and records users with a sensory impairment and facilitates referrals to appropriate services Medium term IAA and prevention/ Service Integration and Pooled Funds/ WCCIS Sensory Impairment OR1;
OR6		 N1; N2; N3; N4; N5; N6 Regional approach to be developed
2.18 Ensure assessment and care planning approach identifies and records users with experiencing VAWDASV and facilitates referral to appropriate services Short term IAA and prevention/ Service Integration and Pooled Funds/ WCCIS VAWDASV OR1;
OR3		 N1; N2; N3; N4; N5; N6; N9; N10; N11; N12 Regional approach to be developed

Note: The Overarching Recommendation from the Population Assessment OR2 applies to all objectives