@Home – accelerating the ambitions of A Healthier Wales in developing locality based integrated care  


The region has brought together learning from the Integrated Care Fund (ICF) and Transformation Fund, to develop a major programme of work to reshape the delivery of health and social care in the region.

The @Home programme brings together a number of projects funded through the Integrated Care Fund and the Transformation Fund including:

  • Multidisciplinary clusters where people can access a range of services based on key priorities of the local area;
  • ICF Integrated discharge service working with the Transformation Fund Get Me Home project to assist in coordinating discharges by working across traditional boundaries;
  • Making services support easier to access through single points of contact – the Cardiff Independent Living Service and Vale Single Point of Access.

MDT Cluster development  

The transformational work around the Cardiff Southwest Cluster has seen significant improvements in patient care with fewer unplanned hospital attendances clearly demonstrated in comparison to other clusters. The cluster development project in Cardiff South West, focussed on 4 key areas of development: 

1. Community based Multi-Disciplinary Team (MDT) meeting for supporting our most vulnerable patients. The regular MDT discussed 294 unique patients in 2021/22. 

2. A wellbeing and discharge coordination hub – to support patients around their discharge from hospital following emergency admissions. The hub contacted 6152 patients in 2021/22. 

3. A community development service to develop and maintain a network of community development activities.  In addition, a network of wellbeing connectors and social prescribing workers to support our patients to improve their wellbeing. There were 730 referrals through the cluster’s social prescribing platform in 2021/22. 

4. A focus on advance care planning to support patients to make and share decisions about their preferred place of care. There were 419 advance care planning discussions held with patients in 2021/22. 

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