Bristol Rehabilitation Current State

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1 Bristl Rehabilitatin Current State Disclaimer: This dcument sets ut a high-level verview f hw rehabilitatin, reablement and enablement services are currently prvided in Bristl and hw thse services interact. Every effrt has been made t ensure accuracy, but fr the sake f clarity descriptins f sme services have been simplified and generalisatins may have been made. This dcument is nt a definitive r cntractual specificatin fr the services described and patients may nt be able t access services in the way described where this is nt clinically apprpriate r where they d nt meet the access criteria fr services.

2 Bristl rehabilitatin current state Cntents Page 1 Intrductin 3 2 Current rehabilitatin, enablement and reablement mdel f care in Bristl Preventin and maintenance First pint f cntact with health and scial care Initial Assessment Medical treatment and rehabilitatin prvided in acute hspital Medical treatment and rehabilitatin in the cmmunity 13 3 Current and pssible service develpments 17 Versin n. 1.0 Status Final Authr Hayley Burtn Apprver Rehabilitatin Prject Bard Date fr apprval/ 4 th March 2013 Date apprved Agreed circulatin Public Versin Date Reviewer Cmment th January, 2013 Hayley Burtn Initial draft th February, 2013 Hayley Burtn Additins fllwing meeting with UHB therapy leads th February, 2013 Hayley Burtn Additins fllwing meeting with Liz Suttn th February 2013 Luke Culverwell Minr amendments t GPSU sectin th February 2013 Hayley Burtn Changes t intermediate care and HSC OT service cmments frm Jayne Cliffrd th February 2013 Hayley Burtn Changes t cmmunity cmplex neur service th March 2013 Hayley Burtn Creatin f final dcument th March 2013 Luke Culverwell Attached disclaimer and final prep fr publicatin Hayley Burtn February 2013 M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 2 f 18

3 Bristl rehabilitatin current state 1. Intrductin It is the aim f the Healthy Futures Rehabilitatin, Enablement and Reablement Prject t agree the future mdels f rehabilitatin services that will perate acrss Bristl, Nrth Smerset and Suth Glucestershire. Details regarding the review prcess, including the scpe f the prject, can be fund in the prject dcument n the prject website (http://www.avn.nhs.uk/rehabilitatin/dcuments/). In the first phase f the prject (Prject Initiatin) tw wrkstreams were set up with the challenge f describing what rehabilitatin, enablement and reablement services are currently running in bth the acute and cmmunity settings fr each f the three BNSSG areas. The services prvided in Bristl have been described in detail in sectin 2 f this dcument. Any prpsed develpments t current services in Bristl which are in discussin, r a decisin has been made but changes nt yet in place have been described in sectin 3 f this dcument. Fr detailed descriptins f services prvided in Suth Glucestershire and Nrth Smerset please refer t dcuments entitled Suth Glucestershire Rehabilitatin Current State and Nrth Smerset Rehabilitatin Current State. 2. Current rehabilitatin, enablement and reablement mdel f care in Bristl 2.1. Preventin and maintenance There has been a shift within the NHS in fcus frm sickness and cure, t wellness and preventin, which reflects in the fact that the management f lng term medical cnditins and ther issues relating t ld age are f increasing cncern. Preventative service may fall under ne f the fllwing categries: Screening and mnitring Anticipatry care planning Self referral Risk stratificatin Signpsting Patient educatin Self management Lng term scial care supprt This prject will nt be fcusing n preventative services; there is hwever anther Healthy Futures prject which fcuses n imprving this part f patient care. In this sectin, sme f the services that are currently prvided in Bristl, which aim t keep peple healthy and independent have been listed. Screening and mnitring Telehealth: There are remte mnitring devices available t patients with COPD r Heart Failure frm Bristl Cmmunity Healthy. As part f this service daily recrdings are sent t a named clinician frm a device used in the patient s M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 3 f 18

4 Bristl rehabilitatin current state hme, thrugh a secure IT netwrk. Clinicians will lk at the daily recrdings and mnitrs the patient s cnditin remtely. Risk stratificatin Falls preventin: There is a lt f wrk current being dne by UHB (inpatients and utpatients) with regards t fall preventin. Signpsting Care Direct: This is the main way the public can cntact adult scial care at Bristl City Cuncil. An advisr at care direct will give infrmatin, advice and tell the individual abut ther rganisatins that will be able t help them. The service is accessible by telephning , 8.30am t 5pm Mnday t Friday (answer phne utside ffice hurs). Well Aware: The Care Frum, six lcal authrity/nhs partners and thers have cme tgether t develp a cmprehensive database f health, wellbeing and cmmunity resurces in Bristl, Bath & Nrth East Smerset and Suth Glucestershire. This accessible at r by phning (freephne) Third sectr / vluntary / supprt grups: In Bristl there are a number f rganisatins which prmte independent living and ffer infrmatin r rehabilitatin/reablement services and supprt. This is nt an exhaustive list but prvides an example f sme f the rganisatins where help and supprt can be sught: WE Care & Repair Living (previusly the Disabled Living Centre) British Red Crss (Hme frm Hspital service, supprt at hme service, dementia supprt and medical equipment) Age UK Bristl The Carers Supprt Centre Bristl Black Carers and ther BME carer supprt grups Bristl Area Strke Fundatin Headway Bristl Frenchay Hspital Cardiac Supprt Grup British Lung Fundatin (Breathe Easy supprt grup) Actin fr Blind peple(bristl Rehabilitatin Service fr peple with a visual impairment) Parkinsns UK Bristl and ther neurlgical supprt grups Patient educatin Diabetes and Nutritin service: Bristl Cmmunity Health prvides fur different types f free curses within the cmmunity in Bristl, Nrth Smerset and Suth Glucestershire t help peple with diabetes manage their cnditin. The curses available are fr: Adults newly diagnsed with type 2 diabetes Adults with type 2 diabetes and wh use insulin M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 4 f 18

5 Bristl rehabilitatin current state There are tw curses fr adults with type 1 diabetes, ne lking at skills fr life and the secnd lking at fd freedm with insulin adjustment. Patient educatin prvided by UHB: There are lts f services ffered by UHB which fall under the banner f patient educatin. Patient Educatin is cre t the prgrammes ffered at SBCH fr Out Patients. These include mvement disrders, neur, fallers sessins, vice clinics, nutritin (nt just diabetic prgrammes) and rheumatlgy. Self management Assistive Technlgy and Telecare devices: Bristl City Cuncil supplies a range f the mst ppular types f equipment t adults wh are eligible fr a service frm Health and Scial Care. This includes telecare equipment and standalne assistive technlgy. The equipment is supplied by the cuncil and can be viewed at Living in Fishpnds, Bristl. A wider range f equipment is available that the cuncil des nt usually pay fr, but is available fr the public t buy. Healthy Hearts (Phase IV) Cardiac Rehabilitatin: Phase IV f cardiac rehabilitatin is a lng-term service prvided by Bristl City Cuncil that invlves nging exercise and the maintenance f lifestyle changes. These classes and gym sessins are run by instructrs qualified thrugh British Assciatin f Cardiac Rehabilitatin (BACR).This service is available t anyne wh has, r has had angina, cardiac surgery, a stent fitted r crnary heart disease (CHD). There is a small charge fr these sessins and many f the sessins are run n a drp in basis nce the patient has been referred, s patients d nt have t cmmit t attending every week. Bristl's Healthy Hearts exercise classes currently run at: Centre fr Sprt, Exercise and Health (University f Bristl) Eastn Leisure Centre Greenway Centre Henbury Leisure Centre Hengrve Park Leisure Centre Hrfield Leisure Centre Merchants' Academy Sprts Centre Suth Bristl Sprts Centre The Park Sprts Centre University f the West f England Better Breathing Classes: Better Breathing classes are run by Bristl City Cuncil and designed t help respiratry patients t exercise under supervisin f trained instructrs at their lcal leisure centre n a lng term basis. These classes are fr peple with respiratry cnditins wh already have experience f exercise under medical supervisin with the pulmnary rehabilitatin team and want t cntinue. There is a small charge fr these sessins and prices vary accrding t leisure centre. Better Breathing classes currently run at: Eastn Leisure Centre, Greenway Centre Henbury Leisure Centre Hengrve Park Leisure Centre, M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 5 f 18

6 Bristl rehabilitatin current state Hrfield Leisure Centre Merchants Academy Sprts Centre The Park Sprts Centre Brunel Fitness Centre Lng term scial care supprt Lng term scial care supprt: Bristl City Cuncil prvides a range f care packages t supprt peple living at hme, such as regular visits frm a dmiciliary care wrker. The packages f care are crdinated by a Care Manager and are reviewed annually s the care package can be adjusted if the needs f the persn change. Peple pay fr these care packages either in full r via a cntributin after a means testing prcess. Extra Care husing: Enables lder residents t live independently in their wn hme, with a range f care and supprt services available n site 24 hurs a day, seven days a week. Residents have their wn self-cntained hmes, with their wn frnt drs, usually in flats, bungalws, r retirement villages. Shared facilities such as restaurants, health and fitness suites and hbby rms are als available n site. Over the last ten years, Bristl City Cuncil has wrked in partnership with husing and care prviders t deliver 600 extra care hmes in eleven schemes acrss the city. Mbile Meals: This service is prvided by Bristl City Cuncil and prvides a chice f ht meals directly t peple's hmes between 11am and 2pm seven days a week. Alternatively meals can be delivered frzen fr mre flexibility. Peple have t pay fr the meals. Other independent meals services als prvide delivered meals acrss the city. Day centres and services: Day centres prvide peple with supprt, activities and scial cntacts. This is prvided at the centre r by assisting peple t use services in the cmmunity. Each day centre is usually prvided fr a specific grup fr example lder peple r disabled peple. Respite care: Respite care prvided by Bristl City Cuncil can help carers r an lder r disabled persn caring fr themselves at hme. Smene else takes n the caring fr a shrt time. Respite care can be arranged as: Day respite - by prviding mre supprt at hme r a day services place Residential respite - shrt term stays in a care hme r anther setting Charges fr respite care based n peple s ability t pay. Peple can als make respite care arrangements privately with hme care r nursing agencies, sitting services, care hmes, day services r by emplying a persnal assistant. Sitting services: Carers can arrange fr smene t cme in the huse and sit with the persn they care fr. Integrated Carers Team: Bristl City Cuncil and NHS Bristl have cme tgether as partners t cntinue and imprve their supprt fr carers. Carers M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 6 f 18

7 Bristl rehabilitatin current state wh are nt eligible fr ther services prvided by the cuncil can apply fr a persnal budget which can be used flexibly. Carers persnal budgets are ften spent n: Having a shrt break away Jining a gym r taking up a hbby Buying equipment r services that make caring easier Occupatinal therapy, equipment and adaptatins: A Bristl City Cuncil service which help lder and disabled peple t remain living independently at hme, and supprt carers by: prviding advice abut living independently at hme prviding equipment like a raised tilet seat arranging minr adaptatins like a stair r grab rail arranging majr adaptatins such as a level-access shwer r a stair lift This service is fr anyne wh has lng-term physical prblems which mean that they have difficulty in getting int r ut f their hme, r carrying ut particular tasks in their hme. It is nt fr peple wh have shrt-term prblems that are expected t imprve. Advice, equipment and minr adaptatins are free t thse wh qualify. Majr adaptatins may require a financial cntributin. Care and Repair: prvide hmewners and private tenants aged 60 and ver a range f services such as financial and welfare advice, help with disability adaptatins, list f apprved cntractrs First pint f cntact with health and scial care An individual will enter the rehabilitatin mdel f care when their health r scial needs change. This change maybe planned, such as ging int hspital fr a planned prcedure, r it may be the result f a slw deteriratin in a persn s health, r a rapid deteriratin r crisis. If there is a change in need a patient r their carer in Bristl may make first cntact with health and scial services in ne f the fllwing ways: By visiting the GP/ GP ut f hurs Bristl GP practices: There are 56 general practices in the Bristl lcality GP Out f hurs: Currently when Bristl GP surgeries are clsed, patients calls are either directed t Brisdc ( ), r Frendc if registered with a Nrth Bristl practice ( ). These services perate after 18:30hrs weekdays, vernights and at weekends/bank hlidays. After 19 th February patients whse ut f hurs service is currently prvided by Brisdc will be directed t call 111 when their GP practice is clsed. The peratrs at 111 will prvide an initial triage, and then pass the patient n t Brisdc if they feel this service is apprpriate. Frm 19 th f March GP practices wh currently use Frendc will direct all f their ut f hurs calls t NHS111. By calling NHS Direct/NHS 111 M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 7 f 18

8 Bristl rehabilitatin current state NHS Direct: The public can currently call NHS Direct n t seek expert health advice and infrmatin at all times f the day r night. NHS 111: NHS Direct will sn be replaced by NHS 111 which is a new service that is being intrduced t make it easier t access lcal NHS healthcare services. Peple will be able t call 111 when they need medical help fast but it s nt lifethreatening. By visiting a Walk in Centre Walk-in Centre at Bts in Bradmead: All members f the public can access the Walk-in Centre, staffed with experience nurses, with n referral r appintment (unless the patient wuld like t be seen after 4pm Mnday - Saturday r after 3:30pm n Sunday). By visiting a Minr Injuries Unit / Urgent Care Centre Minr Injuries Unit at Suthmead Hspital: The minr injuries unit at Suthmead is run by a team f highly qualified nurse practitiners. This service is pen 9am t 9pm, seven days a week. If an injury requires a specialist pinin, patients can be transferred t an apprpriate specialty r the emergency department at Frenchay Hspital. Urgent Care Centre at Suth Bristl NHS Cmmunity Hspital: The Urgent Care Centre prvides all the services f a Walk-in Centre with the additin f being able t refer fr n-site x-rays and ther diagnstic tests. The centre, staffed by nurses trained in dealing with minr injuries and illnesses. N appintment is necessary; patients can just turn up t during pening hurs (8am-8pm). By visiting a lcal Emergency Department (ED) Patients wh g directly t ED: ED departments in Bristl are lcated at the BRI and Frenchay Hspital. By calling 999 In a critical r life-threatening situatin: If 999 is called in situatin that is deemed critical r life-threatening in Bristl they may be taken by Great Western Ambulance Service (GWAS) t either the ED at the BRI r Frenchay Hspital. Categry C cases: There is currently a pilt in place with GWAS in which they assess the categry c cases (lwest need) t see if they culd be dealt with mre successfully by Rapid Respnse. By cntacting Scial services directly By calling Care Direct: The service is accessible by telephning , 8.30am t 5pm Mnday t Friday (answer phne utside ffice hurs). M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 8 f 18

9 Bristl rehabilitatin current state 2.3. Initial Assessment Hspital Assessment & Diagnsis This dcument fcuses n acute services prvided by University Hspital Bristl (UHB), hwever it is acknwledged that sme Bristl residents may use services prvided by Nrth Bristl Trust and ther acute hspitals ut f the Bristl area. Services prvided by Nrth Bristl Trust have been described in the Suth Glucestershire Rehabilitatin Current State, and services prvided by Westn General Hspital have been described in the Nrth Smerset Rehabilitatin Current State. REACT: This service is an admissin avidance service lcated in the emergency departments at the BRI and Frenchay Hspital. REACT is prvided by Bristl Cmmunity Health in-reaching int the Emergency Departments. The REACT service aims t maximise a patient s independence by identifying thse wh are suitable fr the Intermediate Care Service. The service prvides safe and effective access, assessment and care fr individuals accessing the hspitals whilst preventing avidable admissins t the hspitals, and premature admissins t residential and nursing hmes. The REACT team will arrange fr a member f the intermediate care team t cme t patients hme t initiate treatment in the cmmunity. General Practitiner Supprt Unit (GPSU): This service is based next t the Emergency Department at the BRI. Fllwing discussin with the referring GP the duty GP in the unit will either see the patient in the GPSU r direct them t an alternative assessment area e.g. ED r MAU. GPSU has access t hspital diagnstics and medical pinin in rder t assist in determining the apprpriate curse f treatment. Assessment by the UHB therapy team: If there is a decisin t admit the patient t the BRI frm ED, the patient will enter a medical r surgical pathway. The patient will initially be admitted t an assessment bed where they will be seen by a member/members f the therapy team within the first 24 hurs f being admitted. Physitherapy and ccupatin therapy wrk n a blanket referral basis and all patients that are admitted will be seen by a member f the team Patients will be referred specifically t Speech and Language therapy if necessary Patient s nutritinal status will be screened by the nurses after admissin and will be referred t the nutritin and dietetic team if necessary Very few patients will see a psychlgist as part f their rehabilitatin Patients wh are admitted will be cntinually assessed and treated in parallel by the therapy and wider multidisciplinary team. Cmmunity Referral, Assessment & Diagnsis Discharge f patients frm BRI and referral t cmmunity: If the patient needs cntinued supprt in the cmmunity pst discharge the therapy team frm the BRI M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 9 f 18

10 Bristl rehabilitatin current state will refer them t ne r mre f the cmmunity services prvided by Bristl Cmmunity Health r Bristl City Cuncil. The therapy staff at the BRI will crdinate the referral and will need t knw which cmmunity service is the mst suitable t refer the patient n t. Often patients will be referred t mre than ne service, r may receive cmmunity services alngside utpatient services. The patient assessments cnducted by the acute team are nt currently accepted by cmmunity teams. Once referrals have been prcessed cmmunity discharge assessments take place by cmmunity in reach teams. Rehabilitatin services prvided by Bristl Cmmunity Health: The lngerterm rehabilitatin services prvided by Bristl Cmmunity Health take their wn referrals. There is currently n SPA r crdinated jint assessment prcedure fr these services. Intermediate Care SPA: There is a single pint f entry int the Bristl Intermediate Care Service which cvers bth the step-up and step-dwn elements prvided thrugh a single phne number and via a standardised frm. The SPA takes calls frm referrers and btains sufficient infrmatin t screen referrals against agreed criteria. The SPA staff member will undertake an initial phne assessment and then make a decisin regarding the predminant need f the patient, ie nursing, therapy r scial care. Where a persn is nt deemed eligible fr supprt within the service, the SPA staff member is respnsible fr referring the persn t an alternative service prvider. An apprpriately qualified prfessinal will visit the service user fr an assessment f health and scial care needs and prvide /arrange any care required. Eligible step-up referrals will be respnded t n the same-day r next day, and step-dwn referrals within 48 hurs. A care plan will be agreed with the service user, including clear gals and timescales. Assessment thrugh Care Direct: If an individual calls Care Direct and requires further supprt frm the adult scial care team at Bristl City Cuncil smene frm care direct will carry ut an assessment ver the phne. They will then either: Set up supprt ver the phne Refer the patient t the reablement service Arrange fr smene t visit t carry ut a mre detailed assessment. They can help set up and manage the individuals care. Cuncil plicy is t mve twards a system whereby all patients referred fr care and supprt f any kind are screened thrugh the rehabilitatin and reablement service. Once patients have been rehabilitated t ptimal ptential, hmecare will be arranged t supprt any remaining care needs. Majr prperty adaptatins are als requested thrugh Care Direct. Requests are triaged by a cuncil OT. Equipment may be prvided immediately, fr all ther requirements, the patient will attend an assessment centre and will then g n fr full assessment if necessary. Assessment centres and majr adaptatins are prvided by the cuncil s neighburhd and husing M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 10 f 18

11 Bristl rehabilitatin current state directrate and the criteria and standard f prvisin required are determined by statute Medical treatment and rehabilitatin prvided in acute hspital At University Hspitals Bristl (UHB) the fur therapy services (Physitherapy; Occupatinal Therapy, Speech and Language Therapy, Nutritin and Dietetics) are delivered thrugh the clinical services divisins. In-Patients rehabilitatin Strke patients: Patients receive early assessment and rehabilitatin by therapists n the Acute Strke Ward and are set sme early gals fr therapy which are usually related t feeding, sitting, balance and mbility. There is clear Ryal Cllege Physician guidance n strke, s the pathway is written and standards it describes audited Trauma Patients: The trauma ward at the BRI cntains patients with multiple types f injuries including fast-track fractured neck f femur pathways. Slw stream rehab pathway is delivered at Suth Bristl Cmmunity Hspital General Medical Patients: High incidence f respiratry cnditins. There is a nteable level f admissins linked t addictin f drugs and alchl General surgery Patients: General Surgery wards at the BRI including vascular patients and amputees. Older peple: Older peples wards at the BRI Onclgy Patients: These patients are based at Bristl Haematlgy and Onclgy Centre Cardiac Patients: Patients are based at the Bristl Heart Institute and start the first phase f a cardiac rehabilitatin prgramme pst surgery. Respiratry Patients: Includes COPD, Cystic Fibrsis and Asthma patients n the respiratry wards at the BRI - includes 6 high care beds ENT and Head & Neck Patients: Based n wards at the BRI, Bristl Haematlgy and Onclgy Centre, and St Michaels Hspital Wmen s Health/Gynae Patients: Based at St Michaels Hspital Neur Patients: In-patient neur rehabilitatin capacity at the BRI is very limited and there is n dedicated resurce r specialist leads. An initial acute assessment is prvided and initial rehabilitatin and treatment. Head injuries are generally managed n the trauma wards, and ther neurlgy patients are managed acrss a variety f medical wards acrss the BRI. Majr trauma patients: There are majr trauma patients wh are transferred frm NBT t UHB. There are n majr trauma rehabilitatin cnsultants at UHB. Out-patient rehabilitatin Mst utpatient s services prvided by UHB are delivered frm the BRI, althugh there are sme utpatient clinics run frm Suth Bristl Cmmunity Hspital and ther health centres. Patient can be referred t ut-patents after an acute phase as an in-patient r directly frm the cmmunity. Whether r nt a GP refers a patient t M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 11 f 18

12 Bristl rehabilitatin current state utpatient services prvided by UHB r cmmunity services prvided by BCH depends n the lcatin f the GP practice and their referral pathways. Out-Patient prvisin frm Occupatinal Therapy and Physitherapy: Musculskeletal patients Amputees Rheumatlgy patients Heamphilia patients Patients experiencing pain Wmen s Health patients Respiratry patients Neur patients Cardiac patients Hand Trauma patients Strke patients Fallers Frail & Elderly patients Out-Patient prvisin frm Speech & Language Therapy: Neur patients Strke patients Vice Lss patients ENT patients Dementia patients This service als prvides assessment and treatment via hme visits e.g. patients in nursing hmes ften related t dysphagia management. Speech and Language therapy is alternatively prvided as part f intermediate care r DART in the cmmunity. Out-Patient prvisin frm Dietetics: Patients with GI cnditins Pst-abd surgery patients Head and Neck cancer patients Diabetic/pregnant patients Weight management patients Entral feeding in the cmmunity patients There are currently n cmmunity dietetic services available t refer these patients n t, s patients either attend an ut-patients appintment r return t the care f their GP. Specialist inpatient rehabilitatin The 2012 Natinal Specialist Definitin Set specifies that it is the respnsibility f the Specialist Cmmissiners managed by the Natinal Cmmissining Bard frm 1 st April 2013 t cmmissin inpatient neurlgical and spinal crd rehabilitatin. Bristl Neur/Spinal patients wh require inpatient rehabilitatin may be referred t treated in the fllwing lcatins: Brain Injury Rehabilitatin Unit, Frenchay Neur rehabilitatin at the Ryal Natinal Hspital fr Rheumatic Disease, Bath M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 12 f 18

13 Bristl rehabilitatin current state Duke f Crnwall Spinal Treatment Centre, Sailsbury 2.5. Medical treatment and rehabilitatin in the cmmunity Rehabilitatin Beds fr Slw-stream Trauma, Strke and Older peples rehab: UHB have rehabilitatin beds lcated at Suth Bristl Cmmunity Hspital (SBCH). Patients wh require further rehabilitatin and are unable t manage in the cmmunity due t a level f unpredictable health needs r functinal ability are referred frm the BRI t ne f the 56 rehabilitatin beds (15 Strke rehab, 41 lder peple s) at SBCH. These patients require a high level f nursing and therapy input. Early Strke Supprted Discharge Team: This service is fr patients at the BRI and SBCH wh can be discharged and receive cntinued rehabilitatin at hme r in a care hme depending n where the patient lives. Early supprted discharge means that the patient is able t leave hspital early, and thus enjy the benefits f being at hme, but als have intensive therapy five days a week t aid their recvery. The ESD team will prvide care between ne and tw weeks, depending n the needs f the individual patient and the prgress they make. Intermediate Care and Reablement: Bristl Cmmunity Health and Bristl City Cuncil's Health and Scial Care team wrk in partnership t prvide urgent r planned healthcare assessments fr peple in their wn hmes r place f residence. The service is fcused n helping peple t live as independently as pssible and includes nursing, therapy and scial care. This is a nn-chargeable service. There are tw elements t the service: Step-up: Delivered t avid admissin t an acute hspital bed r lng term care. This may include service users with a predminant health need in a crisis situatin (related t their wn r a carers health), r predminant therapy r supprt need identified as requiring reablement ver a lnger perid. This element aims t ensure peple are treated in a setting apprpriate t their need and nly admitted t hspital if they cannt be supprted elsewhere. A service user will be seen in their wn hme r mved t a nn-acute residential setting. Step-dwn: Fcuses n facilitating timely discharge frm an acute hspital bed r an Emergency Department, ensuring service users d nt enter lng term care direct frm a hspital setting, except in exceptinal circumstances. The service is accessed n a planned basis t supprt rehabilitatin and reablement. Hspital based teams prvide a link with the Intermediate Care services in the cmmunity and help facilitate the discharge f patients frm hspital care. A patient will have a care-c-rdinatr during their time in intermediate care t ensure the plan f care is carried ut by the nminated prfessinals/services, within agreed timescales, and t mnitr and review prgress against gals. The care-crdinatr reviews the plan f care at regular intervals, at least nce every tw weeks t mnitr prgress. At the pint f discharge frm the service it is the rle f the care c-rdinatr, M:\Strategic Develpment\Healthy Futures Prgramme (New)\Delivery Prjects & Prgrammes\P12 Rehabilitatin\Design service mdels\lcal Design Meetings\Bristl\Current state\bristl_rehabilitatin_current State_v1.1.dc Page 13 f 18

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