A Delivery Framework For Adult Rehabilitation

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1 A Delivery Framework For Adult Rehabilitation Dr Sarah L Mitchell Project Manager

2 Process involved in delivering the Framework for adult Rehabilitation April 2006 July 2006 Consultations with service users, carers and health and social care professionals August 2006-October 2006 Draft document circulated for3 month consultation February 2007 Delivery framework for Adult Rehabilitation launched

3 Recommendations formulated from service users, evidence base and policy context Access (12 recommendations) Location (4 recommendations) Enablement and self care (7 recommendations) Sustainable multi-professional teams (4 recommendations) Evidence base (2 recommendations) Capacity (3 recommendations)

4 Rehabilitation matters! The framework - concentrates explicitly on the added value offered by rehabilitation through earlier anticipatory interventions and the prevention of unnecessary admissions to hospital; explores how rehabilitation can produce health gains for individuals and communities through enabling return to productive activity and employment provides guidance to underpin the development of rehabilitation in a multi-disciplinary, multi-agency context Offers a clear vision to individuals, carers and services in delivering this vision

5 Challenges Move away from a reactive, unplanned and episodic approach to rehabilitation Re-design of services to ensure this can be achieved True integration of community rehabilitation teams and local authority teams Provision of earlier interventions for those individuals going onto sickness benefit Develop case management approaches within integrated rehabilitation services

6 Links with other Scottish Executive work streams Changing lives Joint Improvement Team Intermediate Care Review of Nursing in the Community Workforce plus an employability framework for Scotland Shifting the balance of care (D4H) Community Hospital Strategy CHP Toolkit Mental health delivery plan

7 New Model for rehabilitation Providing seamless transitions Stage 1 - Self management - early interventions with emphasis on health promotion could be referred to as pre-habilitation or habilitation. Stage 2 Locality based co-ordinated rehabilitation teams providing condition / case management approach Stage 3 Acute phase fast track MDTrehabilitation teams facilitating discharge back to community rehab teams Provision in model for in reach and out- reach

8 The rehabilitation process Case management has been defined as: a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual s health needs through communication and available resources to promote quality costeffective outcomes.

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10 Four priorities for Health Boards and Local authorities Transform their rehabilitation services to put rehabilitation at the heart of service delivery; Adopt a whole-systems approach to rehabilitation services; Give greater priority to rehabilitation services; Reflect evolving outcomes measures for community care (and any consequent targets) that impact on rehabilitation services.

11 Five Key actions National Implementation Group will be formed Local Rehabilitation Co-ordinators established for each health board area Rehabilitation Improvement Programme explored with Joint Future Unit and JIT A Managed Knowledge Network established A rehabilitation research consensus event will be held

12 Remit for the Rehabilitation Co-ordinators Scope the existing rehabilitation/enablement services across health and social care within the NHS board area and pull together all current worksteams across CHPs, Secondary and tertiary care into an area wide implementation plan. With the support of the NIG and the improvement programme, lead on local re-design to ensure that integration of health and social care rehabilitation services is achieved within designated timescales. Facilitate the development of, and build on existing Board-wide service improvement plans in collaboration with the health, social care, voluntary and patient and public partnership groups.

13 Remit for the Rehabilitation Co-ordinators Through multi-agency pathways transform processes and systems Work in conjunction with the national and local programme managers, local falls co-ordinators, MCN Leads and collaboratives to ensure that falls and bone health strategies are implemented across health and social care. Ensure the implementation plan takes forward rehabilitation elements of national policies/initiatives, and includes any rehabilitation elements from CHPs long term conditions action plans.

14 Remit for the Rehabilitation Co-ordinators Work closely with service users and carers and public partnership groups to ensure their contribution to planned service improvements. Ensure that through collaborative working transitions of care and the patient journey are seamless and efficient. Provide local support for the implementation of the managed knowledge network for rehabilitation. Take the lead responsibility in ensuring dissemination of the information and evidence to local health board area

15 HDL - Falls NHS Boards need to have a combined falls and bone health strategy which CHP will implement CHPs need to appoint a falls prevention lead or coordinator to work along side the rehab coordinators CHPs need to develop an operational falls prevention and bone health implementation strategy

16 Falls Mapping Study High Level evidence from 2003 The Scottish Context Mapping Falls Prevention Activity On line questionnaire to each board area Three health board areas reviewed in-depth with 6 depth interviews with key personnel

17 Falls Mapping Study Evidence Desk based literature search from 2003 ( after the NICE guideline ) found 856 relevant publications on falls prevention, risk minimisation, assessment demonstrating a high level of activity this area Scott Porter Research and Marketing

18 Falls Mapping Study The Scottish Context All Our Futures: Planning for a Scotland with an Ageing Population (2007) Delivery Framework for Adult Rehabilitation (February 2007) HDL Rehabilitation and Falls (2007) SEHD Falls Working Group (April 2006) Changing Lives (2006) National Framework for Service Change (2005) Delivering for Health (2005) Taking Positive Steps to Avoid Trips and Falls (February 2003) Adding Life to Years: Report of the Expert Group on Healthcare of Older People (January 2002) Falls Prevention Conference (November 2002) Joint Future (2000)

19 Falls Mapping Study Mapping Exercise focusing on: existing falls prevention strategies/implementation plans systems and facilities in place for assessing those at risk of a fall extent of implementation of multifactorial interventions tools developed to support falls prevention falls prevention training/education currently available to staff health promotion approaches used with older people existing network and support groups examples of good practice.

20 Falls Mapping Study Summary of Key Issues Need for a culture change in relation to falls Need for clear direction from policy, board and local authorities Falls coordinators/leads are a crucial link Need for standardised assessment tools and data capture Sharing and dissemination strategy Available evidence base and best practice Training for staff Health Promotion Primary prevention as well as secondary prevention

21 Next Steps Falls Programme Manager (October 2007) Managed Knowledge Network ( rehabilitation and falls) Community of practice for falls ( 2 year work programme )

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