Goal 1: Co-ordination planning and support for populations at greater risk of needing urgent or emergency care

To help prevent future Urgent or Emergency Care presentations, populations at greater risk of needing to access them should expect to receive proactive support through enhanced planning and coordination of their health and social care needs. This should support better outcomes, experience and value.

Quality Statement:

·        Parents or guardians of children in ‘Early Years’ settings will be supported to anticipate risks of childhood accidents in the home. 

·        People eligible to access the Welsh Government’s Nest Warm Homes scheme are offered support to improve their resilience and well-being, through improving the health of their homes. 

·        People living with multiple long-term conditions are offered an opportunity to participate in regular holistic reviews and to co-produce a personalised care plan. This should include an offer of involvement to carers in conversations about care plans. This should cover the carer’s own needs to help prevent admission to hospital for the person for whom they have caring responsibilities for non-clinical reasons, in the event of sudden illness for the carer. 

·        People with frailty syndromes, including those with dementia, are proactively identified by health and social care teams to ensure they receive care by a team of professionals competent to assess and manage individual needs at, or closer to, home. 

·        Community teams support individuals who are lonely, socially isolated or excluded through social prescribing schemes, awareness of them and encouragement and support for their use. 

·        People with mental health issues will be supported through early identification and intervention in primary care. They will be empowered to access self-help and community support. 

·        People with substance misuse issues receive support to reduce their risk of harm through access to advice from the right professional. They can access rehabilitation, recovery services and psychologically informed care. 

·        Residents of care homes and people known to be at greater risk of falling, are offered proactive support through home safety checks, home adaptations and advice on adoption of healthy behaviours appropriate to their needs. 

·        People with a progressive life-shortening illness have the offer of agreeing an advance care plan through close collaboration between the person, their families and carers; and the professionals involved in their care to enable them to die in the place of their choice.

To read more about Goal 1 including initial priorities, how health and social care systems will be supported to achieve this goal and how success will be measured, please refer to the Six Goals for Urgent and Emergency Care Policy Handbook.

Goal 1 Lead: Rhian Matthews, Professional Advisor / Policy Integrator (Frailty and Integrated Community Care System for Older People), Welsh Government - ABB.SixGoalsUEC@wales.nhs.uk