Integrated care and support

An integrated care and support pathway

In terms of care and support needs, our Population Assessment identified a number of common challenges and opportunities across the different population groups. It demonstrated that a collaborative, preventative approach based on improving population health and reducing and delaying the need for care and support is going to be crucial if we are to help people achieve positive outcomes, remain independent and live fulfilled lives within our communities. We have strong foundations on which to build although it is clear that we need to accelerate the pace of change. This will require a fundamental shift in the balance between community-based, preventative support and acute services and an associated change in funding priorities. This shift is illustrated in the following diagram, which has been developed by HDdUHB but is applicable across health and social care.

In view of the cross-cutting nature of many of our challenges and opportunities, we have structured our Plan to span the needs of the entire population through a co-produced, preventative approach to care and support reflected in a staged care and support pathway. This approach aligns with our commitment to prevention outlined above and national work that is underway to develop consistent models of seamless, integrated, locality-based care.


Our care and support pathway aims to support people to:

  1. Stay well and independent within the community (for example through ‘self care’ programmes and improved management of personal health and wellbeing, helping children and young people to develop healthy behaviours through their formative years provision of Information, Advice and Assistance, tackling mental ill health at an early stage, linking people with well-being hubs and informal support within their communities and further development of extra care and supported living services) – Prevention Stage 1

  2. Maintain independence through provision of targeted support that prevents the need for people to be admitted to hospital or long-term residential care, or supports timely discharge (such as domiciliary care, housing adaptations, ‘turnaround’ services at the front door of hospitals and rapid response services, ‘step-up’, ‘step-down’ and reablement services, supporting families and parents to reduce adverse childhood experiences (ACE) which can have life- long effects, building on the work of the Integrated Family Support Service to work with and support the most vulnerable children and families in Wales) – Prevention Stage 2

  3. Receive, where appropriate, outcomes-focused long-term care and support (for example through ongoing health and/or social care in residential settings with a focus on supporting independence, building on strengths and improving outcomes for individuals over time, working to reduce unnecessary levels of care) – Prevention Stage 3


Section 3 of the Plan provides a high level Delivery Plan containing a range of objectives grouped under the three stages of our preventative approach, with an additional section detailing objectives in relation to the ‘enablers’ within the RPB’s priorities. For each objective we indicate which population groups will be affected by the planned change (linking directly back to the Chapters in our Population Assessment and the summary information contained in Section 2), and which of the eight regional priorities set out above apply. We also cross-refer each objective to the overarching recommendations within our Population Assessment.

Next page