Rehabilitation Network Strategy Final Version 30 th June 2014

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1 Rehabilitation Network Strategy Final Version 30 th June 2014

2 Contents Foreword 3 Introduction Our Strategy 4 Overview of the Cheshire and Merseyside Rehabilitation Network 6 Analysis of our strengths, weaknesses, opportunities and strengths 8 The drivers for specialist rehabilitation services 10 Our Strategic Objectives Actions we need to take to deliver a service pathway across the Rehabilitation Network 13 Actions we need to take to deliver patient focused services 14 Actions we need to take to deliver cost efficient services 15 Actions we need to take to deliver a high calibre, flexible workforce with specialist rehabilitation expertise 16 Actions we need to take to work in partnership to deliver high quality audit, research and innovation to drive excellent patient care 17 Implementing our Rehabilitation Network Strategy 18 2 Rehabilitation Network Strategy

3 Foreword Foreword We are pleased to present the Cheshire and Merseyside s Rehabilitation Network s first 3-year Strategy. Since January 2013, the Rehabilitation Network has provided specialist rehabilitation for patients following traumatic injury or illness across a whole systems model of care; this provides us with a unique opportunity to deliver a co-ordinated pathway across hospital and community. We work in partnership with The Walton Centre NHS Foundation Trust, St Helens and Knowsley Teaching Hospitals NHS Trust, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Wirral University Teaching Hospital NHS Foundation Trust, Mersey Care NHS Trust, Bridgewater Community Healthcare NHS Trust, Liverpool Neuro Physio, and Health and Social Care Partnerships. The Rehabilitation Network promotes equitable and timely access to the right level of specialist rehabilitation care. Our mission is to provide specialist rehabilitation care, underpinned by best practice, research and education to optimise the clinical outcomes of Cheshire and Merseyside patients. We recognise that to achieve our mission we need to work collaboratively with all our partners across the pathway. This approach provides opportunities for us to strengthen specialist rehabilitation expertise, and develop a culture of learning with education and research at its core to support the delivery of high quality specialist rehabilitation services. This strategy identifies the five key strategic objectives and actions over the next three years. We welcome the engagement and involvement of our staff, patient representatives and stakeholders in the implementation of this strategy. Chris Harrop Peter Enevoldson Louise Jenkins Sponsor Chief Executive Sponsor Medical Director Manager Rehabilitation Network Rehabilitation Network Rehabilitation Network Rehabilitation Network Strategy

4 Communications and Engagement Strategy Audit, Research and Innovation Strategy Workforce and Education Strategy Introduction Introduction Our Strategy Why do we need a Rehabilitation Network Strategy? The Cheshire and Merseyside Rehabilitation Network is committed to delivering high quality specialist rehabilitation services from hospital to community. This Strategy has been developed to support the Rehabilitation Network in the delivery of its strategic objectives and sets out the direction of travel over the next three years. It will be supported by a suite of strategies and supporting implementation plans and programmes (see Figure 1). Figure 1: Framework to support delivery of the strategies and supporting work programmes/plans. Rehabilitation Network Strategy The aim of the strategy is to achieve greater synergy across the services to optimise the potential of a proactive approach to the continuous improvement and delivery of specialist rehabilitation services to patients following traumatic injury or illness. Our mission is to deliver high quality specialist rehabilitation care underpinned by best practice, education and research. The strategy summaries our high level plans for to enable us to continue to make progress towards realising our mission. Mission Our purpose Mission To provide specialist rehabilitation care, underpinned by best practice, research and education to optimise the rehabilitation outcomes of Cheshire and Merseyside patients Rehabilitation Network Work Programme Implementation Plan Implementation Plan and Programme Implementation Plan and Training Plan 4 Rehabilitation Network Strategy

5 Introduction How has the Rehabilitation Network Strategy been developed? This strategy has, and continues to be, developed following discussions with staff and situation analysis of our services. The Rehabilitation Network Strategic Board has been involved in the development of the strategy. Formulation of this strategy is a joint initiative with our partners, including: The Walton Centre NHS Foundation Trust; St Helens and Knowsley Teaching Hospitals NHS Trust; Royal Liverpool and Broadgreen University Hospitals NHS Trust; Wirral University Teaching Hospital NHS Foundation Trust; Mersey Care NHS Trust; Bridgewater Community Healthcare NHS Trust; Liverpool Neuro Physio; Health and Social Care Partnerships. Rehabilitation Network Strategy

6 Community Specialist Rehabilitation - St Helens and Knowsley Service 55 patient case load Overview of the Cheshire and Merseyside Rehabilitation Network Overview of the Cheshire and Merseyside Rehabilitation Network The key drivers for implementation of the Rehabilitation Network were: to provide equitable, co-ordinated and local access to appropriate levels of specialist rehabilitation, regardless of diagnosis; to address the increased demand following introduction of the major trauma collaborative; and to provide a specialist multi-disciplinary approach to rehabilitation, achieving optimal clinical outcomes. The provision of specialist rehabilitation services within the Rehabilitation Network across inpatient, outpatient and community services is summarised below. Specialist Rehabilitation Service Hyper Acute Rehabilitation Unit - The Walton Centre Complex Rehabilitation Unit - The Walton Centre Spoke Rehabilitation Units - St Helens Hospital - Broadgreen Hospital Extended Rehabilitation Unit Oak Vale Gardens Outpatient Services - Consultant outpatient appointments delivered at Hub and Spoke Units Annual Forecast Activity 40 admissions 80 admissions 60 admissions 45 admissions 16 admissions 754 outpatient attendances (based on ) - Therapy 6 outpatient Rehabilitation appointments Network delivered Strategy at 1,800 outpatient attendances Spoke Units A key strength of the Hub and Spoke Specialist Rehabilitation Units is our ability to provide a wide range of clinical expertise including Rehabilitation Consultants, Occupational Therapists, Physiotherapists, Respiratory Physiotherapists, Dieticians, Speech and Language Therapists, Nurses, Consultant Neuro-Psychiatrist, Mental Health Liaison Nurse, Consultant Psychologists and Rehabilitation Co-ordinators. Hub Hyper Acute Rehabilitation Unit The Hyper Acute Rehabilitation Unit is based at The Walton Centre as part of the hub provision for Cheshire and Merseyside patients. The Unit provides early stage supportive rehabilitation for patients stepped down from Critical Care, High Dependency Units or Major Trauma Centres to promote optimal recovery and improved clinical outcomes. We are one of four Hyper Acute Rehabilitation Units in the country. We are the only Hyper Acute Rehabilitation Unit to provide both major trauma and neurological rehabilitation. Hub Complex Rehabilitation Unit The Complex Rehabilitation Unit is based at The Walton Centre as part of the hub provision for Cheshire and Merseyside patients. The Unit provides supportive rehabilitation for patients through comprehensive multi-disciplinary assessment and rehabilitation. The Unit supports those patients who are transferred from the Hyper Acute Rehabilitation Unit or Tertiary or District General Hospitals or a referral from the GP or community services.

7 Overview of the Cheshire and Merseyside Rehabilitation Network Overview of the Cheshire and Merseyside Rehabilitation Network (continued) Spoke Rehabilitation Units The Spoke Rehabilitation Units are based at St Helens and Broadgreen Hospitals for Merseyside patients. The Units provide active rehabilitation to promote functional independence and return home. The Units support those patients who are transferred from the Hub Rehabilitation Units, Tertiary or District General Hospitals or referred from their GP or community services. Extended Rehabilitation Unit The purpose built Extended Rehabilitation Unit is based at Oak Vale Gardens in Liverpool for Merseyside patients. The Unit offers slow stream rehabilitation for a period of months for patients who have complex nursing needs (e.g. tracheostomy, low awareness and other complex presentations). The Unit is medically managed by two local GP Practices. The Rehabilitation Consultants from the Network provide fortnightly outpatient clinics. The multi-disciplinary team includes Nursing, Occupational Therapy, Physiotherapy, Speech and Language Therapy, Psychology and a Case Manager. Outpatient Services The Rehabilitation Consultants provide medical outpatient services for Cheshire and Merseyside patients who have been discharged from the Hub or Spoke Rehabilitation Units or referred by their GP or community services. We provide occupational therapy and physiotherapy outpatient services at St Helens and Broadgreen Spoke Units for Merseyside patients who have been discharged from the Hub or Spoke Units or referred by their GP or community services. Community Specialist Rehabilitation Services Since April 2013 we have been responsible for providing community specialist rehabilitation services for patients from St Helens, Knowsley, Liverpool, South Sefton and Southport and Formby Clinical Commissioning Groups. These services are provided from a range of sites in St Helens and Liverpool including within people s own home. We provide therapy and psychological rehabilitation programmes and case management for patients following a period of inpatient rehabilitation or those who are referred by their GP or community services. Single Point of Contact and Bed Management Service We provide a single point of contact for referrers, patients and carers to support timely and appropriate access to specialist rehabilitation services along the pathway according to complexity of rehabilitation need. Our Bed Management Service supports timely admissions to the Hub and Spoke Rehabilitation Units and monitors patient flow. Network Management Team We provide strategic and operational management to promote collaborative working across the partner organisations in relation to performance, education and development and research. Rehabilitation Network Strategy

8 SWOT Analysis Analysis of Our Strengths, Weaknesses, Opportunities and Threats for the Rehabilitation Network Strengths Weaknesses 1. Specialist rehabilitation expertise and multi-disciplinary teams. 2. Patient experience and satisfaction. 3. Regionally integrated service delivery of inpatient, outpatient and specialist community services across a co-ordinated pathway. 1. Gap in spoke provision for Cheshire patients. Risk: Failure to deliver the benefits of this strategy to all patients within the region. Risk Mitigation Strategy: Work with commissioners to develop approach. 4. Family support groups. 5. Market leader dominant provider within Cheshire and Merseyside for specialist rehabilitation. 6. Partnership working across units and services within the pathway. 7. Partnership working with specialist commissioners. 8. Track record of delivery we have a history of meeting waiting time targets, efficient length of stay, a significant percentage of our patients are discharged home and demonstrate good rehabilitation outcomes. 9. Good relationships with stakeholder Networks and Organisations 10. Staff engagement in continued development of the Rehabilitation Network. 2. Relationships with Continuing Health Care to support discharge planning. Risk: Inability to support timely discharges. Risk Mitigation Strategy: Continue to engage with commissioners to support the process. 3. Difficulties in attracting sufficient specialist trainees in rehabilitation medicine to the local Deanery training scheme. Risk: Inability to provide sufficient medical cover. Risk Mitigation Strategy: Explore opportunities to develop staff grade posts within the Rehabilitation Network. 8 Rehabilitation Network Strategy

9 SWOT Analysis Analysis of Our Strengths, Weaknesses, Opportunities and Threats for the Rehabilitation Network (continued) Opportunities Threats 1. Develop a Spoke Rehabilitation Unit for Cheshire patients to provide a more efficient and effective service. 2. Develop mechanisms to share practice as evidenced by patient and carer feedback. 3. Adopt a marketing approach to raise the profile and benefits of the Rehabilitation Network. 4. Capture staff experience to continually support service improvements. 5. Patient/ carer membership on strategic groups. 6. GP Relationships Brand, Model and Reputation. 7. CSU Relationships - Brand, Model and Reputation. 8. Develop reputation and promotion of research, clinical audit and innovation. 9. Develop reputation and promotion of training and education. 10. Develop hospital outpatient clinics to deliver improved patient focused care pathways to ensure that for each individual the Right Care is provided in the Right Place at the Right Time (e.g. MDT Clinics, Gait Analysis Clinics). 11. Use the service review/evaluation to identify drive a tried and tested model of care to deliver quality, efficient and value for money services. 12. Explore areas for innovation and service development and potential scope for increasing the market and geographical catchment for the Rehabilitation Network. 13. Develop working relationships with the North West EATs. 14. Explore opportunities to extend rehabilitation skills to other patient groups. 1. Changes in future commissioning arrangements/strategy/intentions. Risk: Potential destabilisation of service provision. Risk Management Strategy: Work closely with Commissioners to develop services to meet patient needs. 2. Introduction of tariff less than sustainable may result in destabilisation of financial plans. Risk: Potential destabilisation of financial plans. Risk Management Strategy: Work closely with Commissioners to develop mutually beneficial approach to capacity planning. Rehabilitation Network Strategy

10 The drivers for specialist rehabilitation services National The drivers for specialist rehabilitation services We have assessed the external and internal drivers for specialist rehabilitation services in the development of this strategy. Examples of the drivers are listed below. Cheshire and Merseyside Specialist Commissioners National Service Specification for Specialist Rehabilitation Increasing focus on specialist rehabilitation following major traumatic injury or illness and realisation of realisation of impact on other health services due to scarce and/or inefficient rehabilitation services Increasing focus on provision, access and quality in rehabilitation Increasing focus on benchmarking specialist rehabilitation service staffing, bed occupancy, rehabilitation complexity and outcomes Increasing focus on audit to raise service standards Cheshire and Merseyside Clinical Commissioning Groups The need to achieve clinically and financially sustainable services for clinical commissioning groups local populations Optimal rehabilitation outcomes based on best outcomes for patients Provision of locally commissioned services Commissioning standards for delivery of high quality specialist rehabilitation services Local Clinical Commissioning Group commissioning intentions The need to achieve clinically and financially sustainable services across Cheshire and Merseyside Commissioning standards for delivery of high quality specialist rehabilitation services Optimal rehabilitation outcomes for patients Rehabilitation Network Working collaboratively to deliver specialist rehabilitation services that meet commissioned standards Deliver and promote quality services demonstrated through patient safety, experience and outcomes/clinical effectiveness Capture, learn from and promote best practice in clinical, operational and financial performance Capture and learn from referrer and commissioner experience Making best use of innovation to improve service provision and patient outcomes Recruit and develop a flexible, skilled workforce 10 Rehabilitation Network Strategy

11 Our Strategic Objectives Our Strategic Objectives We have set ourselves five strategic objectives to ensure that we deliver our mission. These are set out below: Strategic Objective 1: Establish a service pathway across the Rehabilitation Network The Rehabilitation Network aims to develop a sustainable service that addresses specialist rehabilitation needs, regardless of diagnosis, in the most appropriate levels of care across inpatient, outpatient and community settings. The Rehabilitation Network recognises its vital role of central organisation and integration of the service and these pathways. As a Network our clinicians and managers are committed to working in partnership to lead and promote evidence based care to provide our patients with rehabilitation opportunities along the pathway to optimise their functional recovery. The NHS is facing increased demands for its services at a time when there are reduced resources available. It is integral that the Rehabilitation Network engages with specialist commissioners and clinical commissioning groups to secure continued support and funding following the pilot period ending March Strategic Objective 2: Deliver patient focused quality services The Rehabilitation Network vision for high quality, compassionate patient-centred care is a key tenet in its strategic initiative and has been adopted as a high level objective to inform strategic plans and work plans. This will be achieved by working with patients, carers and public involvement and engagement to embed compassionate patient-centred care. The Rehabilitation Network will work closely with patient support groups, voluntary organisations and patient, advice and liaison services to develop service initiatives to support continued service development. Strategic Objective 3: Deliver cost efficient services The Rehabilitation Network recognises the investment by commissioners to establish a whole systems model of care across inpatient, outpatient and specialist rehabilitation community services. We will explore ways of optimising the measurement of clinical and system outcomes across the Rehabilitation Network and the use of our clinical facilities and workforce across the Rehabilitation Network to demonstrate value and to maximise the return on investment. Rehabilitation Network Strategy

12 Our Strategic Objectives Our Strategic Objectives (continued) Strategic Objective 4: Attract and retain a high calibre, flexible workforce with specialist rehabilitation expertise The Rehabilitation Network aims to attract, develop and retain a high calibre rehabilitation workforce. The Rehabilitation Network has recognised a multi-disciplinary team approach ensures that our patients receive the best care and treatment in line with evidence based practice. The Rehabilitation Network will work closely with Directors of HR and Organisational Development to incorporate workforce planning, training and development in HR plans. Strategic Objective 5: Work in partnership to deliver high quality clinical audit, research and innovation to drive excellent patient care The Rehabilitation Network aims to embed clinical audit, research and innovation as core business for developing and maintaining high quality patient-centred rehabilitation services. As a specialist Rehabilitation Network our clinicians and managers are committed to undertaking clinical audit and research and ensure lessons learned from these research and audit findings translate into clinical practice. This should include the export of the model of the Rehabilitation Network itself and its organisations to other regions of the NHS. We will embark on strategic collaborations with all partners to develop and support the delivery of long term, sustainable programmes of research and audit. The Rehabilitation Network will explore clinical audit and research collaborations with local health care organisations and academic institutions, and where appropriate with industry. The Rehabilitation Network is in a unique position to develop partnerships and collaborations locally and nationally to begin to build and promote its reputation for high quality clinical audit, research and innovation. We will work closely with the Sponsor Organisation s Research and Audit Team to effectively develop and implement clinical audit, research and innovation across the Rehabilitation Network. 12 Rehabilitation Network Strategy

13 Actions we need to take to deliver a service pathway Actions we need to take to deliver a service pathway Improve systems and processes to support effective partnership working across the pathway Develop and promote our reputation as a specialist rehabilitation network Enhance clinical, operational and financial performance Service pathway across the Rehabilitation Network Maximise benefits of collaborative and partnership working Enhance and further develop our services and facilities to meet patient need Develop policies and guidelines to provide high quality care Strategic Objective 1: A service pathway across the Rehabilitation Network By 2017 we will: Deliver equitable and sustainable specialist rehabilitation services for patients across the pathway from hospital to community Deliver comprehensive and joined up rehabilitation services as part of a co-ordinated rehabilitation pathway Have further integrated social care as part of the multidisciplinary team Be a leading provider of quality specialist rehabilitation across hospital and community services Work closely with Tertiary and District General Hospitals, Major Trauma Centres and Units, critical care services, primary care, social care and healthcare commissioners to deliver specialist rehabilitation services for our patients following traumatic injury or illness. Be the specialist rehabilitation service of choice for Cheshire and Merseyside Have a national and international reputation for providing high quality specialist rehabilitation services Promote a service pathway across the Rehabilitation Network through implementation of the Communication and Engagement strategy Rehabilitation Network Strategy

14 Actions we need to take to deliver patient focused services Actions we need to take to deliver patient focused services Work with patients and carers to support continuous service improvement Develop patientcentred compassionate care across the rehabilitation network Develop patient information to improve patient safety, experience and outcomes Patient focused quality services Make our systems and processes more patient focused 14 Rehabilitation Network Strategy Maximise the potential of IT to improve patient experience and outcomes Improve the experience and outcomes of patients through integrating services Strategic Objective 2: Delivery of patient focused services By 2017 we will: Have developed services that are flexible and adaptable to meet the changing needs of our patients Continue to deliver on our key performance indicators and service standards Have Network policies that endorse quality care and performance Have improved local access to hospital and community specialist rehabilitation services for patients in Cheshire and Merseyside Have improved facilities that promote privacy and dignity Continue to work with patients, carers and staff to embed patient-centred and compassionate care. Have provided patients and carers with opportunities to be involved in and influence development and further improvement of services Continue to have an efficient and effective Network bed management system that supports timely access and appropriate level of rehabilitation care Involve patients in identifying research questions and design of research studies Continue to share good practice and success stories across the pathway to improve patient experience and outcomes

15 Actions we need to take to deliver cost efficient services Actions we need to take to deliver cost efficient services Work with commissioners to develop robust and sustainable service provision Improve systems and processes to maximise value for money Ensure the infrastructure and facilities maximise return on investment Cost efficient services Promote innovative practice and share developments across services Develop robust and transparent reporting system for operational and financial performance Use performance outcomes to identify improvements to make best use of our resources Strategic Objective 3: Delivery of cost efficient services By 2017 we will: Have optimised the use of our clinical workforce and facilities to ensure value for money across the pathway Deliver sustainable services across the pathway from hospital to community Have a transparent and robust reporting system for activity and financial performance monitoring to maximise return on investment Share cost information with clinical leads to improve efficiencies in the rehabilitation care they deliver Have robust channels of communication with commissioners for financial and contractual performance Continue to identify cost improvement opportunities to make best use of resources Use research outputs and innovation to support service improvement to make effective use of resources Share good practice in cost-effective services (e.g. use of technology) Rehabilitation Network Strategy

16 Actions we need to take to deliver a high calibre, flexible workforce Actions we need to take to deliver a high calibre, flexible workforce Work closely with education and practice partners to support trainee and student placements Embed learning within practice at all levels Develop a culture that promotes patient safety, experience and outcomes Attract and retain a high calibre, flexible workforce Establish a robust infrastructure to support delivery of excellent education 16 Rehabilitation Network Strategy Develop a highly skilled and engaged workforce championing our vision and values Implement innovative education and training programmes Strategic Objective 4: A high calibre, flexible workforce with specialist rehabilitation expertise By 2017 we will: Continue to promote an open culture that values staff contributions to service improvements Have shared vision and values embedded within our culture across the Rehabilitation Network Provide staff with opportunities to participate in education and development Continue to identify staff training and development needs aligned to service delivery and contexts of care Deliver innovative education and training programmes that follow patient pathways rather than organisational boundaries to support the development of specialist rehabilitation expertise amongst all staff disciplines and grades Have a culture of partnership and collaboration to consider and address local, regional and national priorities Have developed close partnership working with Higher Education Institutions and practice partners to provide opportunities for student and trainee placements Enhance recruitment by promotion of our Rehabilitation Network culture and outcomes through research and innovation Create a culture to support activities across the workforce through implementation of the Clinical Audit, Research and Innovation Strategy

17 Actions we need to take to deliver high quality audit, research and innovation Actions we need to take to deliver high quality clinical audit, research and innovation Promote our reputation for audit, research and innovation nationally and internationally Increase opportunities for patients/carers to participate and benefit from research Develop a culture that places research, audit and innovation at its core High quality audit research and innovation Promote the outputs of audit, research and innovation Engage staff in audit, research and innovation improve safety, experience and clinical outcomes Harness research and innovation to continuously improve clinical services across the pathway Strategic Objective 5: Work in partnership to deliver high quality clinical audit, research and innovation to drive excellent patient care By 2017 we will: Have embedded research, audit and innovation as core Network business, providing opportunities for involvement of all staff groups Continue to develop Rehabilitation Network programmes of research, audit and innovation to improve clinical outcomes and patient experience across the pathway Be recognised regionally, nationally and internationally as a Network which encompass research and audit into evidence based practice Have developed partnerships with academic institutions to support and promote research and innovation at pace and scale Have increased the number of academic publications and success of research funding Have increased the opportunities for patients and carers to participate in and benefit from research Develop a culture that supports and enables activities to improve patient care through implementation of the Clinical Audit, Research and Innovation Strategy Utilise research and innovation to enhance recruitment of high quality staff across the UK. Rehabilitation Network Strategy

18 Implementing our Rehabilitation Network Strategy Implementing Our Rehabilitation Network Strategy It is important that we are able to fully realise our mission and demonstrate the successful implementation of the strategic objectives set out in the strategy. Implementing our Rehabilitation Network Strategy We have a robust framework for the delivery of our strategy to provide high quality clinical care, education and research to optimise the rehabilitation Mission outcomes of Cheshire and Merseyside patients. There are a number of steps in this process and these are set out below. Work in partnership to deliver the Rehabilitation Network Strategy Whilst staff have been involved in the development of this strategy, we will ensure that they fully understand what is meant by it and that we work together effectively to implement it. Supporting strategies This strategy is a high level framework and will be supported by a range of strategies including: communication and engagement; workforce and education; and clinical audit, research and innovation. Development of annual work programmes Implementation of this strategy will be supported by an annual work with key actions and timescales to deliver against the five strategic objectives. 18 Rehabilitation Network Strategy Annual Work Programmes Supporting Strategies High quality specialist rehabilitation services Collaborative and Partnership Working Vision and Values Strategic Objectives

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