Chronic Conditions Management Programme:

With the service moving towards
integrated service delivery, NLIAH has
recognised the need to consider its
programmes and capacity support on a
themed basis. This has been endorsed
by the Service Level Agreement with
WAG and other key stakeholders. This
approach will enable the NHS and other
stakeholders to have an overview of the
full range of capacity support provided by
NLIAH both locally and nationally.
Chronic Conditions
Management Programme:
The themed approach in NLIAH
Innovation House · Bridgend Road
Llanharan · CF72 9RP
Tel: 01443 233333 · Fax: 01443 233334
www.nliah.wales.nhs.uk
NLIAH has been tasked by the Welsh Assembly Government (WAG)
to provide targeted support to all health communities in Wales with
the implementation, and development, of their Chronic Condition
Management (CCM) action plans. This will be a new programme for
2008/2009, but will build on work already undertaken with pathways.
The CCM agenda will form the first integrated theme within NLIAH
designed to help health communities with the reconfiguration of
services, and the provision of improved care aimed at:
• encouraging patients to self-manage;
• improving GP referral rates, reducing hospital admissions,
outpatient referrals, and lengths of stay;
• developing more appropriate points of care, particularly within the
community setting;
• improving resource utilisation; and
• reducing prescribing costs.
NLIAH support
NLIAH can undertake a wide range of support functions
including:
• general support and advice on the development and execution of
local action plans to meet the challenges of the 2008-2011 Service
Improvement Plan;
• advice on the use of service improvement tools and, in particular,
process mapping and plan, do, study, act (PDSA) cycle methodology;
• advice on CCM policy, strategy documents, current thinking
and models;
• advice on pathway, and Integrated Care Pathways development including signposting
to source documentation (and links to implementation and demonstrator sites);
• advice and expertise on the new integrated workforce planning process;
• support to enhance the ability to work in collaboration;
• bespoke skills4change training; and
• leadership and development training.
Demonstrator Site Support
There are three CCM Demonstrator sites across Wales: Carmarthen LSB, North
Wales (Wrexham LSB & Gwynedd LSB) and Cardiff LSB. A National Co-ordinator
is in the process of being recruited, and will be hosted by NLIAH. We will also
provide targeted support to these sites.
The aim of the sites is to provide an opportunity to implement the CCM Framework
through focused effort, support and resources in localities to test and learn across
organisational and professional boundaries. Outcomes will be delivered and
reported on at regular intervals and practical solutions will be worked through and
used to support further mainstreaming across Wales.
There are four core workstreams:
• strengthening integrated community services planning and delivery processes;
• information services and technology infrastructure;
• workforce development; and
• engaging local support and involvement from local people, patients, carers
and communities in service design and delivery.
Supporting this approach there will also be enabling workstreams focusing on:
leadership; organisational development and culture; governance; research
and evaluation.
Central to the Demonstrator sites is an integrated approach to service,
workforce, capital, IT and financial planning; reflecting the new approach
to integrated workforce planning across Wales.
Bespoke work
Alternatively, NLIAH managers can undertake bespoke packages of
work for health communities independently, or in conjunction with
other NLIAH colleagues. This support, which should be linked to
Designed for Improvement plans and Modernisation Assessments, can
be fairly wide ranging and may encompass the broader NLIAH resource
but should still be based on focussed outcomes, clearly defined
deliverables, and a project agreement. Examples of such work might
include undertaking minor reviews and surveys of current services,
stakeholder analysis, audit and research or the mapping of pathways.
Bespoke project support of this nature would not normally be expected
to last any longer than four months.
Data analysis
Each health community will have access to limited support from the
NLIAH data analysis team, and will be given a named point of contact.
This can include the training of health community staff to undertake
basic data analysis or, alternatively, the NLIAH team can undertake more
complex work on behalf of health communities.
Workshop support
NLIAH can provide capacity support for those health communities
who wish to organise formal workshops or events. This can include the
booking of venues, administration of delegates, production of publicity
and workshop materials, catering arrangements, visual aid provision, and
support staff on the day.

Funding is available and this may, in some circumstances, include
reimbursement for locum fees. NLIAH representatives are always on hand
to provide facilitation at workshops, meetings and break-out sessions.
Liaison
NLIAH are keen to facilitate partnership working between stakeholders,
particularly in the context of reconfiguration and merger proposals.
More importantly, NLIAH will act as a conduit for health communities
throughout Wales, sharing and communicating ideas and progress
(particularly, through the NLIAH web portal), facilitating networks and
communities of practice, and will undertake some reporting functions
when deemed appropriate.
THE WELSH CHRONIC CONDITIONS MODEL
Proactive and Planned Management of Chronic Conditions
Pathway development
NLIAH will maintain contact with all organisations that have previously
developed CCM pathways as part of the Integrated Care Pathway
programme and will act as an ongoing support mechanism to support
further development.
The CCM team
Dominique Bird, Maria Gallagher, Margaret Rennocks, Garry Smith, Lynne
Bolderson, Beverly Wilding
A team of six Service Improvement Managers will work collectively to
both coordinate, and provide, capacity support to health communities,
but this will not necessarily be on a regional basis. However, each health
community will have a designated NLIAH manager to act as a single point
of contact, and will be asked to assign a Director to liaise with the team,
agree appropriate priorities and outcomes, and to monitor progress.
Change Agent Team (CAT)
Lynda Chandler, Matt Wyatt, Iain Roberts
The Change Agent Team has two work streams which will support
the CCM programme. ‘Passing the Baton’ aims to improve frontline
discharge planning practices, including effective care coordination,
and hence avoid unnecessary readmission. The Supporting Practice in
Intermediate Care Evaluation (SPICE) programme will assist communities
in the development and evaluation of local services that facilitate early
discharge, support independence and avoid unnecessary hospital
admission. The CAT will also support the CCM Programme in the
facilitation of the regional Chronic Conditions Management
Communities of Practice.
skills4change
Chris Matthews, Paul Cottingham, Emma Brady
NLIAH can provide service improvement training and support to help
delegates deliver an improvement project through the skills4change
programme. The team delivers a mixture of regional and organisation
based courses, which can be tailored and are championed by an
executive in the host organisation.
Clinical Support to Health Care
Organisations
Breeda Worthington
The Clinical Support to Health Care Organisations (CSHCO)
Programme has been designed to help busy clinicians’ (doctors, nurses,
pharmacists, physiotherapists etc.) to be involved with improving the
design and way we deliver care to patients. By releasing a small amount
of their time and helping them to understand how their work is done
and organised, and most importantly what it achieves; clinicians’ get an
opportunity to reflect and then test out new ideas about their work so
it is made easier, quicker and better for them and their patients.
PArtnership Development
Siân Harrop-Griffiths, Wayne Jepson
Developing CCM Services in line with the CCM Framework requires local
organisations to work beyond their own internal professional and organisational
boundaries. Service change as expected in the Framework can only be achieved
through working in collaboration on a multi-agency and cross professional basis.
The Partnership Development Programme will support local organisations develop
the skills and capacity to work more effectively on a collaborative basis and on
engaging with citizens on a continuing basis to develop effective local dialogues.
The Partnership Development Directorate also leads the coordination of NLIAH’s
CCM activities and support to the CCM Demonstrator Sites.
Workforce Development
Stephen Griffiths
The NLIAH Workforce Development team are available to support health
communities with an ongoing programme of training and development aimed at
increasing workforce planning capability, and enabling staff to develop integrated
service, workforce, and financial plans.
The programme, part of the implementation of the new workforce
planning process, includes both master classes at board level, and
workforce planning workshops for budget holders and planners.
Workforce Development can also support the CCM Programme with
specialist advice and expertise on the new integrated workforce planning
process, techniques to review current working practices and approaches
to redefine team composition. Local workforce modernisation managers
should be contacted for further information.
Care to Lead
Jo Carruthers
Any complex changes and improved service delivery must be based upon
a foundation of competent and experienced leadership; this is particularly
important when considering the significant divergence of healthcare
systems across Wales. Care to Lead develops home grown talent to
meet the challenges presented by complex and dynamic healthcare
systems through the provision of robust leadership development,
succession planning and talent management systems.