What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?​

Patients are spending too long away away from their home and are exposed to unnecessary harm during their hospital stay. Hospitals and the interface between community are not designed to meet the challenges that come with the complexity of caring for frail patients (>65). Poor communication between community and urgent care often leads to patients being treated generically as a “frail” older person rather than with a wholistic specialised approach.

This work will focus around a number of pathway improvements that between established programmes of work in Cardiff and Vale. These include a Hospital at Home community workstream and secondary care frailty work focussed on quick access to Compressive Geriatric Assessment.

Feedback on work so far – “We are better at rationalising investigations and at discharging people home. Senior decision maker talking to families can be useful with families who are not always keen to have their relative home”​

What does your project aim to achieve?

Objectives 

Quicker access to high quality urgent and emergency care that is attuned to the needs of older people

• Avoidance of admission
• Reduced LOS for those that need admission
• Timely access to Compressive Geriatric Assessment
• Faster return to community

Aim – By  August 2026 older people in Cardiff and Vale University Health Board will spend 20% less time in hospital and return to their usual place of residence

How will the project be delivered?

This project will be adopting a Agile approach utilising a skilled project management team with a focus on benefits realisation

We will work closely with our value based colleagues with a defined measurement plan utilising the health boards data platforms

How is your project going to share learning?

With a solid problem and aim statement we will build on our learning utilising our change skills in the Spread and Scale methodology. We will use fishbowl and  extension agency skills to spread learning across Wales and the UK