The National Data Resource Programme, the NDR, is transforming Health and Care in Wales through a more connected and collaborative system. Let’s explore how the NDR can support the Digital Health & Care Record for Wales in enabling a holistic and personalised care experience
Lewis is getting older, and since his fall at home not long ago, he has been on a Care Plan. He also cares for his wife, Bethan, who is living with dementia. A remote motion sensor was installed in their house to alert family or a 24/7 monitoring centre should either of them have a fall or not be following their usual
One day, Lewis is feeling very tired and hasn’t left the
bedroom. He receives a call from a remote monitoring
centre operator. Lewis is not speaking clearly on the
phone and his Digital Health & Care Record identifies
him as being at risk of a stroke. An ambulance is called
and his close
The ambulance service already have Lewis’ key details
from his Digital Record. The hospital is pre-warned and
plans are immediately put in place to support Bethan
while Lewis is gone. Lewis is taken straight in
Whilst Lewis is being treated his Hospital Social Worker
begins putting together an updated Care Plan using the
existing details from Lewis and Bethan’s Digital Health &
An Occupational Therapist (OT) also assesses what support is
needed at home in order for Lewis to be discharged. The OT can
see Lewis’ Care Plan and works with the Social Worker and
family to make sure it fits
By the time Lewis is medically fit for discharge he already
has a joined up Care Plan in place so he can go home to
Bethan without delay. His family have been fully engaged
in this preparation. He can see in his Health & Care Portal that appointments have been scheduled in for him and prescription
When Lewis gets home, some assistive equipment has already
been installed and a care worker arranged to provide support a
few times a week. The Occupational Therapist soon visits to
check the equipment is appropriate. They speak with Lewis’
Care Worker to see how he is getting on and check Lewis'
priority outcomes with him now he's
Lewis sees a range of health professionals who work together to
help him recover from the stroke. After each visit, his Digital
Health & Care Record is updated so that everyone has a single,
up to date, view of Lewis’ progress. Lewis can keep track of this
himself too via the Health and
As Lewis continues to recover, the reablement team also visit
to put longer term support in place so that Lewis feels
comfortable and capable of continuing to look after Bethan.
Lewis enjoys getting back to cooking and even does some
gardening for the first time
His Care Coordinator recommends a charity volunteering service that can help Lewis with shopping, gardening and caring for Bethan. It’s nice to have the extra company and takes some strain off his own
A few months on, Lewis and Bethan now have a strong support network in place to keep them happy and healthy. Without the joined up work from health and social care, enabled by the NDR, Lewis and Bethan could have been facing a very
