Developed by the Cardiff and Vale Regional Partnership Board, the Me, My Home, My Community project integrates health and social care to bring care closer to home.
It will receive nearly £7m over two years from the Transformation Fund to change, develop and join up health and social care services, with more emphasis on preventing illness, and shifting services out of hospital to homes and communities.
The Transformation Fund has been created to support key actions from the Welsh Government’s long term plan for health and social care, A Healthier Wales.
Me, My Home, My Community is based on partnership working between all parts of the NHS, local authority services, charities and the voluntary sector to ensure individuals and families get the support they need closer to home, at the right time. It aims to maximise independence, which research has shown is the outcome that matters most to people.
The project is informed by a similar initiative developed in Canterbury, New Zealand and has a number of key elements which will improve how health and social services work together:
- Get Me Home and Get Me Home Plus will change the way partner organisations can work together in hospitals. For example local authorities will work with the NHS to provide increased daily contact on the wards. Get Me Home Plus will see people being assessed in their own home after being discharged from hospital, rather than being assessed before being discharged. This will give a clear understanding of the support and adaptations needed in their home, and it will allow people to return home more quickly after a stay in hospital. Wrap-around care at home will be provided by healthcare professionals, social services carers, and social workers.
- A well-being website will link services across the community and allow health and social care professionals to share information about patients.
- Community development officers will develop and recommend community based care – for example community gardening projects, walking groups ‘men’s sheds’, and ‘talking cafés’.
- Developing a well-being workforce. In addition to social prescribers and existing well-being officers, reception staff will be trained to provide information and connect people to volunteer care workers in the community.
- Identifying people who are at risk and actively supporting them to remain as independent as possible. This involves creating better connections between hospitals, GPs, and pharmacists to ensure everyone is informed of individual patients’ needs when they’re discharged from hospital, and patients have one point of contact.
- Multi disciplinary teams, led by a GP, to develop and review services.
During a visit to Redlands Surgery in Penarth today (Thursday 18 October), Health Secretary, Vaughan Gething met members of the Cardiff and Vale team and some of the team visiting from New Zealand to see the development of the project.
Mr Gething said:
“With an increase in life expectancy and our continued public health challenges, our health and social care services will continue to face increasing pressures. This is why, in our long term plan for health and social care, we have set out the need to truly transform the way we deliver care to ensure it is sustainable in the future.
This will require better integration of health and social services to reduce reliance on hospitals and deliver care closer to home. The Transformation Fund will be used to fund a small number of projects which have the most impact in developing and delivering new models of care, and which have potential to scale up so they can be used across Wales.
I am very pleased to announce the first project to be backed by the Fund. The Cardiff and Vale team have a clear vision of how to deliver better care for patients and reduce pressure on GPs and hospitals, and I look forward to seeing this and other new models developed and rolled-out quickly.”
Cardiff Council’s Cabinet Member for Social Care, Health and Wellbeing, and Chair of the Cardiff and Vale Regional Partnership Board, Cllr Susan Elsmore, said:
“This is a tremendous opportunity to fundamentally realign health and social care, not only in the region, but also across the country, in order to deliver the priorities set out by Welsh Government in its Healthier Wales strategy.
“Our programme has families and individuals at its heart. By having this population focus, local authorities and the NHS can work together to deliver preventative services, at a local level, which maintain independence and produce the outcomes people are looking for.
“There has been a lot of hard work undertaken by the members of the Cardiff and Vale Regional Partnership Board to continually improve health and social care. Now is the time to build on this work and place the principles of the new national policy at the forefront of our services.”
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