CCM Demonstrators
The CCM Demonstrator Programme
To help deliver and drive improvements to Chronic Conditions Management (CCM) across Wales, three national service improvement CCM demonstrator projects have been established. The three national CCM demonstrator projects run to March 2011 and are based in the following areas:
Cardiff (from January 2009), Carmarthenshire (from May 2008) and North Wales - Gwynedd(from May 2008).
Aims and Approaches
The aim of the programme is to:
Provide and test a sustainable and affordable generic CCM service model, which supports people’s needs locally and promotes independent living within the community in order to communicate and inform service change across Wales.
The three Demonstrators have a common approach which is to:
•Provide an opportunity to focus effort, support and resources in their localities in order to test and learn across the many organisational and professional boundaries
•Apply the model and develop solutions to support the business case for change whilst identifying lessons and learning. This in turn will then support further mainstreaming and application in practice across the principality of Wales.
With this in mind its is hoped that this approach will better enable a sustainable health and social care response to the ageing Welsh population and the increase in the prevalence of people with chronic conditions. Also, to give a broader demonstration of how changes to services and capacity to meet this demand can be achieved in oder to justify further large scale change in these services in Wales. And finally, to utilise the collective support from a number of local and national agencies in testing and driving improved services and support for local people, such as the national information management and technology (IM&T) programme.
Activities and Key Themes
The CCM demonstrators have faced the need and challenge to begin real change in a complex environment. This has required leadership by demonstrators through executive leads and a single project lead utilising new approaches to partnership working. The key themes of the demonstrators are to try out and test the following at locality level so that they can be adopted by the Local Health Boards (LHB's) and others - and to pass on the lessons learnt during the 'demonstrating':
The Core CCM Service and Team,the Role of the CCM Care Service Planning Co-ordinator,the CCM Generic Support worker,a CCM Generic Care Pathway,the Predictive Risk Management tool for Risk Stratification (PRISM),the Clustering approach of the CCM Model, the Service Development Directives in support of the CCM model,and Information Management and Technology (IM&T) requirements for CCM.''''
Interests
The National CCM demonstrators also have special interests as follows:
The Cardiff demonstrator specialise on the use of a generic care bundle, community diabetes services and leading the Service Development Directive for epilepsy.
The Carmarthenshire demonstrator has a particular focus on IM&T, research and development and the Service Development Directive for chronic respiratory conditions.
The North Wales demonstrator has a special interest in developing: the integrated workforce, public and patient experiences, medicines management / community pharmacy and the Service Development Directives for chronic non-malignant pain, and arthritis and chronic musculoskeletal conditions.
Each of the three Demonstrators is organised so that they have their own local Delivery Board to ensure that there is strong steer and representation from the key players across a wide range of sectors. Nationally there is support from the CCM team in the Welsh Assembly Government and research,programme management and communications from a team hosted by the National Leadership and Innovations Agency for Healthcare (NLIAH).
The Next Steps
Corporate branding has been identified, developed and produced with a demonstrator DVD and website also created. The CCM demonstrators have work plans for the next 12 months which describe activity, planned deliverables, progress and learning impact for ‘non’ demonstrator areas, with a report on progress and achievements in the first 12 recently published.
A number of learning papers have also been produced (12 in total) which further illustrate the demonstrators present work and were released in October 2009.
CCM Demonstrator Learning Paper 1:Communicating the CCM Core Model(May 2009)
CCM Demonstrator Learning Paper 2:Information Management and Technology(IM&T)requirements for CCM (May 2009)
CCM Demonstrator Learning Paper 3:CCM Demonstrator Research and Evaluation (Oct 2009)
CCM Demonstrator Learning Paper 4:CCM Locality Care Co-ordination (May 2009)
CCM Demonstrator Learning Paper 5 (Part 1):The development of Advanced Community Nurse Practitioners supporting the delivery of Chronic Conditions Management (May 2009)
CCM Demonstrator Learning Paper 5 (Part 2):Developing Governance Principles to Support Integrated Working in CCM (May 2009)
CCM Demonstrator Learning Paper 6:What are the National CCM Demonstrators? (May 2009)
CCM Demonstrator Learning Paper 7:Carmarthenshire CCM Demonstrator Frequently Asked Questions (FAQs)(May 2009)
CCM Demonstrator Learning Paper 8:Progress and Achievements in the first 12 months – Executive Summary(Oct 2009)
CCM Demonstrator Learning Paper 9:Evidence and Key Learning Themes – Partnership and Building the Consensus(Oct 2009)
CCM Demonstrator Learning Paper 10:Evidence and Key Learning Themes – the Locality Approach, Clinical Leadership and a Systems Approach(Oct 2009)
CCM Demonstrator Learning Paper 11:CCM Demonstrators – Deliverables, benefits and anticipated outcomes(Oct 2009)
CCM Demonstrator Learning Paper 12:Emerging Outcomes and Evidence of Progress with Partners (Oct 2009)
Further learning papers are currently being written with the first few scheduled to be published in February/March 2010.