Wessex Strategic Clinical Networks. Rehabilitation Reablement Recovery Quality Guidance Document

Transcription

1 Wessex Strategic Clinical Networks Rehabilitation Reablement Recovery Quality Guidance Document

2 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document ACKNOWLEDGEMENTS The Wessex Strategic Clinical Networks would like to offer their sincere thanks and appreciation to all those that have given their valuable time and support to the development of this document. We would like to offer special thanks to the rehabilitation, reablement and recovery steering group, who have collectively driven this programme of work forward. Thanks also go to our stakeholders from health, social care and the third sector who have been part of the workstreams and workshops to develop this document. Their enthusiasm and dedication to improving patient and carer experiences of rehabilitation, reablement and recovery across Wessex was fundamental to the development of this document. Finally we would like to express our sincere gratitude to the patients and carers who offered their stories and advice throughout the development of this document, providing invaluable insight into their experiences of rehabilitation, reablement and recovery and their vision for improvement. 2

3 FOREWORD Asked by the concerned commissioner whether the service he had received after his stroke was good, the elderly gentleman replied that the staff had been lovely but he couldn t comment on the service as it was his first stroke and he had nothing to compare it to. This honest and frank reply highlights the limitations of patients experience and the vulnerability of the public to decisions made on their behalf as to what care they will receive. As health professionals working in stroke care, we have seen the standards of acute care rise inexorably over the past ten years as commissioners and hospital staff have worked together to implement best practice and eliminate many of the previous regional inequities that existed. As a result, acute stroke care is now approaching levels similar to cardiac and cancer care. However, with all these many diseases, once the person leaves the confines of the hospital the inequity in standards of care and rehabilitation becomes apparent. The elderly gentleman did not know that the neighbouring hospitals community services would have supported him to return home early with six weeks of intensive therapy at home, that he could have had a timely wheelchair assessment which would have stopped him developing a pressure sore or a specialist review at six months which would have highlighted and treated his wife s depression and his increasing spasticity. This quality guidance is one of the first regional and national documents that is not disease specific but focused on what local patients, commissioners, health and social care staff and public health professionals have told us are the important considerations for supporting rehabilitation, reablement and recovery in the community. Its intention is not to be prescriptive but rather to provide commissioners and provider organisations with quality requirements and examples of local innovative practice against which they can develop and benchmark their services. Together it is our responsibility to ensure that people have equitable access to quality rehabilitation, reablement and recovery services across Wessex. Dr Hayden Kirk Consultant Physiotherapist Chair of the Wessex Strategic Clinical Networks Rehabilitation, Reablement and Recovery Steering Group I am delighted to be associated with this document, which outlines the approach to rehabilitation, re-enablement and recovery advocated by the Wessex Strategic Clinical Network. This document will give you clear advice on how to commission and develop adult out-of-hospital rehabilitation services. In my numerous visits to NHS organisations around the country it is clear that the care of our patients would be considerably improved by enhanced rehabilitation services. It is my personal belief that rehabilitation within the NHS needs to be transformed, as it has the capacity to deliver the key components of health care which patients value: independence, quality of life and return to work or fulfilling activity. We cannot fully meet our duty of care to our patients unless we incorporate rehabilitation into everything we do. This document is a significant contribution to this approach and I encourage you to refer to it when you plan your future services. John Etherington OBE NCD for Rehabilitation and Recovering in the Community 3

4 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document EXECUTIVE SUMMARY During this review it was evident that both nationally and locally there are areas of excellent provision of rehabilitation, reablement and recovery but with varying levels of adoption and dissemination. It was equally evident that there is also a lack of awareness of what services are available at a service user, provider and commissioning level. Across Wessex there is currently variable provision and different models of rehabilitation, reablement and recovery service with limited data available. Traditionally, both nationally and locally, there has been a focus on patient pathways but this is predominantly for the delivery of acute health and care services and specialist rehabilitation. As is clear from national directives there is a need to improve integration of services and care within the community to meet the ongoing needs of individuals with a variety of conditions. This document provides commissioning advice and guidance to ensure the equitable provision of high quality (cost effective and clinically effective) community (out of hospital) rehabilitation/reablement/recovery for adults across the Wessex region. The focus of this document is the general principles and quality requirements of adult, out of hospital, rehabilitation, reablement and recovery, inclusive of physical and mental health, rather than being focused on a particular condition, or disease specific. It does not cover tertiary specialised commissioning services. Developed in collaboration with patients and carers, health and social care commissioners and providers; and third sector organisations through stakeholder engagement; a set of overarching rehabilitation, reablement and recovery principles have been developed. 4 key quality priority areas were identified by stakeholders and are the main focus of this document: 1. Movement out of hospital Vision: Patients leaving hospital experience a timely and safe transfer of care with a clear understanding of the process, with information and awareness of any of the services they will be receiving in the community. 9 quality requirements are identified encompassing: assessment, outcomes, care plans, key worker, community integration, sharing information, equipment, rehabilitation environment and education. 2. Accessing services: Vision: That all patients and professionals have the knowledge and means to navigate their way through the health and care system to access the services they require. 9 quality requirements are identified encompassing: needs assessment and risk stratification, information and access, communication, choice, timeliness, duration, seven day working, return to work and integration. 3. Supported self-management Vision: Individuals and their carers are enabled to live a full life in the community achieving a good quality of life, maximising their wellbeing, choices and independence whether at home or in a care home. 5 quality requirements are identified encompassing: resources, key contacts, review of needs and care planning. 4. Quality outcome measures and key performance indicators are suggested for each quality priority area. A number of innovative practice examples are given to illustrate how the quality requirements can be delivered. Finally, working together to take this forward considers the service delivery and workforce development implications of this document. 4

5 TABLE OF CONTENTS FOREWORD... 3 TABLE OF FIGURES... 7 DEFINITIONS/ABBREVIATIONS INTRODUCTION Wessex Strategic Clinical Networks Local programme of work Purpose and scope of this quality guidance document Focus area Inclusions Exclusions Developing the Quality Guidance Document Using the Quality Guidance Document Definitions Rehabilitation Reablement Recovery NATIONAL CONTEXT National drivers to improve rehabilitation NHS England Mandate House of Care Integration of services Year of Care Cultural shift The Better Care Fund Local Wessex context Stakeholder engagement and events Key messages from Wessex stakeholders WESSEX REHABILITATION, REABLEMENT AND RECOVERY PRINCIPLES MOVEMENT OUT OF HOSPITAL Vision Quality principles Rationale and evidence base Patients recover better at home Quality requirements

6 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document TABLE OF CONTENT 4.5 Innovative practice examples Quality outcome measures and Key Performance Indicators System measures Process measures Quality outcome measures ACCESSING SERVICES Vision Quality principles Rationale and evidence base Quality requirements Innovative practice examples Quality outcome measures and Key Performance Indicators System measures Process measures Quality outcome measures SUPPORTED SELF-MANAGEMENT Vision Principles Rationale and evidence base Quality requirements Innovative practice examples Quality outcome measures and Key Performance Indicators System measures Process measures Quality outcome measures WORKING TOGETHER TO TAKE THIS WORK FORWARD Service design Workforce development Collaborative working APPENDICES The expectations of good rehabilitation services The principles of good rehabilitation services

7 TABLE OF FIGURES Figure 1: Area map of Wessex...9 Figure 2: Rehabilitation, reablement and recovery quality improvement programme for Wessex Figure 3: The domains of the NHS Outcomes Framework Figure 4: The House of Care Figure 5: Focus of the Quality Guidance Document Figure 6: Conventional care versus Early Supported Discharge Figure 7: 10 integrated services to provide patient-centred care...34 Figure 8: Levels of service

8 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document DEFINITIONS/ ABBREVIATIONS CCGs ESD KPIs LOS LTC(s) NACR NICE OPG QGD SCNs Clinical Commissioning Groups Early Supported Discharge Key Performance Indicators Length of Stay Long Term Condition(s) National Audit of Cardiac Rehabilitation National Institute for Clinical Excellence Oversight and Planning Group Quality Guidance Document Strategic Clinical Networks 8

9 1. INTRODUCTION 1.1 Wessex Strategic Clinical Networks Working together for lifelong quality care 1. NHS Dorset CCG 2. NHS Southampton City CCG 3. NHS West Hampshire CCG 4. NHS North Hampshire CCG 5. NHS North East Hampshire and Farnhan CCG 6. NHS South East Hampshire CCG 7. NHS Fareham and Gosport CCG 8. NHS Portsmouth CCG 9. NHS Isle of Wight CCG 3 Winchester Basingstoke 4 Alton 6 5 Farnham Bordon Dorchester 1 Poole Southampton Lymington 2 7 Portsmouth 8 Bournemouth Newport 9 Figure 1: Area map of Wessex The Wessex area covers a population of 2.8 million people, including the urban and rural areas of Dorset, Bournemouth, Poole, Southampton, Hampshire, Portsmouth and the Isle of Wight (Figure 1). Across Wessex there are: l 9 Clinical Commissioning Groups (CCGs) l 6 Acute Trusts l 3 Community Trusts l 1 Integrated Acute and Community Trust l 7 Local Authorities l 17 District Councils l 6 Health and Wellbeing Boards 9

10 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document 1. INTRODUCTION Strategic Clinical Networks (SCNs) work in partnership with commissioners (including local government), supporting their decision making and strategic planning. The overall aim is to work across the boundaries of commissioner, provider and third sector organisations as a vehicle for improvement in care and outcomes for patients, carers and the public. The role of the Strategic Clinical Networks is to: l Reduce unwarranted variation in health and wellbeing services; l Encourage innovation in how services are provided now and in the future; l Provide clinical advice and leadership to support decision making and strategic planning. Sharing good practice and reducing inequalities 1.2 Local programme of work In Autumn 2013 the Wessex SCNs developed a rehabilitation, reablement and recovery programme of work (Figure 2) with the overall aim: To produce commissioning advice and guidance to ensure the equitable provision of high quality (cost effective and clinically effective) community (out of hospital) rehabilitation/reablement/recovery for adults across the Wessex region in line with NHS England. This includes the development of this rehabilitation, reablement and recovery quality guidance document as well as an out of hospital rehabilitation, reablement and recovery service specification. The aim is that every person receives the right care, given by the right person, at the right time, in the right place. It s the right care, delivered by the right person, at the right time, achieving the right result Patient quote 10

11 Focus - Adult out of hospital community rehab, reablement & recovery across health and social care Aims Right Time Right Place Right Care/ Person Workstreams Accessing services (pathways) Movement out of hospital Supported selfmanagement Measures KPIs and Outcomes Key Deliverables Wessex wide rehab, reablement & recovery quality guidance document Out of hospital adult rehab, reablement & recovery service specification Figure 2: Rehabilitation, reablement and recovery quality improvement programme for Wessex 1.3 Purpose and scope of this Quality Guidance Document The three Wessex Strategic Clinical Networks comprising of Cardiovascular; Cancer; and Mental Health, Dementia and Neurology have committed to this programme of work. The programme also has sign up and engagement from the Oversight and Planning Group, which has representation from all CCGs within Wessex, and wider sign up from regional networks such as the Wessex Major Trauma Rehabilitation Network and a wide range of stakeholders including social care, the third sector, patients and carers. In collaboration with patients, third sector organisations, commissioners and providers from across Wessex, the SCNs have developed this out of hospital rehabilitation, reablement and recovery quality guidance document (QGD) for commissioners. This guidance document aims to: l Provide commissioning advice and guidance to ensure the equitable provision of high quality (cost effective and clinically effective) community (out of hospital) rehabilitation, reablement and recovery services for adults across the Wessex region in line with rehabilitation principles developed by NHS England. 11

12 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document 1. INTRODUCTION 12 l Provide minimum quality standards for rehabilitation, reablement and recovery services for adults and their families in Wessex. l Provide a quality framework to promote and align partnership working to support local services to identify and secure improvements to rehabilitation, reablement and recovery services and address inequalities over the next three years. l Provide advice, guidance and support for commissioners and providers across health, social care and the third sector in the planning, development, procurement and performance management of services. 1.4 Focus area This QGD focuses on adult, out of hospital rehabilitation, reablement and recovery services predominantly to support people to recover from episodes of ill health or injury Inclusions The QGD is inclusive of: l Physical and mental health l The principles of generic rehabilitation, reablement and recovery (not focussed on condition or disease specific rehabilitation) Exclusions The QGD does not apply to: l Children and children s services but accepts that transition services need to be taken into consideration as an interdependency l Tertiary (nationally commissioned) specialised rehabilitation services 1.5 Developing the Quality Guidance Document The QGD does not replace or act as a detailed clinical guideline and is not intended to be inclusive of all out of hospital rehabilitation requirements. This document should be read in conjunction with national guidelines for individual conditions, such as those from the National Institute for Clinical Excellence (NICE). 1 The quality guidance is a representation of the priority areas as identified by patients, third sector organisations, commissioners, public health leads and health and social care providers from across Wessex. These were: 1. Movement out of hospital 2. Accessing services (pathways) 3. Supported self-management 4. Outcome measures (key performance indicators KPIs) The QGD is based on evidence where best evidence is available. This has been drawn together from published evidence where it exists. However, where the evidence base is not clear consensus expert opinion has been sought and emerging recommendations were tested by the steering group through engagement with other key stakeholders. The development of this QGD is in line with NHS England s national work programme to improve rehabilitation services across England led by Col. John Etherington, National Clinical Director for Rehabilitation and Recovery in the Community; Suzanne Rastrick, Chief Allied Health Professions Officer and NHS Improving Quality. 1.6 Using the Quality Guidance Document The document sets out a number of quality principles for each of the broad areas of the QGD, which outline the features of what a good service should look like. Under each quality principle is an explanation of the rationale and evidence base behind why the principle has been set, and a list of the quality requirements needed to meet that standard. It is recommended that going forward, the SCNs work with commissioners to begin to establish a baseline, to determine where commissioners already have plans in place, where there may be gaps and where work is needed. At the end of each section key performance indicators and

13 outcome measures are suggested which would help to establish a baseline. These are intended to help commissioners monitor progress in their own geographical areas. 1.7 Definitions For the purpose of the QGD the following definitions of rehabilitation, reablement and recovery are used Rehabilitation Rehabilitation is the development, to the maximum degree possible, of an individual s function and/or role, both mentally and physically, within their family and social networks and within education/training and the workplace where appropriate Reablement Reablement is the active process of an individual regaining the skills, confidence and independence to enable them to do the things for themselves, rather than having things done for them Recovery A deeply personal, unique process of changing one s attitudes, values, feelings, goals, skills, and roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by the illness. 3 FOOTNOTES Working definition as used by NHS England 3 Anthony WE (1993) Recovery from Mental Illness: the guiding vision of the mental health service system in the 1990s, Psychosocial Rehabilitation Journal, 16,

14 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document 2. NATIONAL CONTEXT 2.1 National drivers to improve rehabilitation Nationally, a set of expectations and principles of good rehabilitation services have been developed through national stakeholder engagement which Wessex as a region support (Appendices). These have been developed in the context of the national drivers to improve rehabilitation which are summarised below. Every year, millions of people rely on the NHS to help them recover after an illness or rehabilitate after injury. It does so through effective treatment and through ongoing help in recovering quickly and regaining independence. NHS England Mandate Refresh NHS Outcomes Framework The NHS Outcomes Framework 5 focuses on quality and outcomes and underpins the work of the Wessex SCNs. Rehabilitation, reablement and recovery are a focus throughout and, although they predominantly sit under Domain 3 Helping people to recover from episodes of ill health or following injury, they are a consistent theme across Domains 1 5 (Figure 3). Domain 1 Domain 2 Domain 3 Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Effectiveness Domain 4 Ensuring people have a positive experience of care Experience Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm Safety Figure 3: The domains of the NHS Outcomes Framework 14

15 2.1.2 House of Care Integration of services Rehabilitation, reablement and recovery are integral to Domain 2 enhancing the quality of life for people with long term conditions, integration of services and the model of the House of Care 6 (see figure 4). It is estimated that 70% of health and care resource expenditure is consumed by long-term conditions (LTCs) 7. The health and care system needs to adapt to meet the needs of the individual, where the individual is central to how care and services are designed and implemented. The House of Care is a framework to support this philosophy, underpins this QGD and supports enhancement of the quality of life for people with LTCs regardless of their individual conditions. Organisational and supporting processes Engaged, informed individuals and carers Person-centred coordinated care Health and care professionals committed to partnership working Commissioning Figure 4: The House of Care 6 The House of Care takes a whole system approach to LTC management. It makes the person central to care. It is about aligning levers, drivers, evidence and assets to enhance the quality of life for people with long term conditions no matter what or how many conditions they have. NHS England (2014) 8 15

16 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document 2. NATIONAL CONTEXT Year of Care Cultural shift The Year of Care is another national driver which underpins the rehabilitation, reablement and recovery agenda, putting the individual at the heart of care planning and commissioning of services. The work of the Year of Care was the foundation for the development of the House of Care framework and is based around the premise of improving care for people with LTCs in the NHS. It describes the ongoing care a person with a LTC should expect to receive in a year, including support for self-management, which can be costed and commissioned. It uses collaborative care planning to put the individual at the centre of their care, supporting them to self-manage. Through collaboration, the local services needed to support individuals are identified and made available through commissioning. Nationally there is a drive to change the historical cultural beliefs around rehabilitation, reablement and recovery to an inclusive view of them, where rehabilitation, reablement and recovery are considered to be integral to recovery from illness or injury as an essential rather than an adjunct to treatment or a nice to have. Rehabilitation, reablement and recovery are for everyone and not just for those with specialist needs. This cultural shift also challenges the traditional medical model of health care as that of a hospital bed based care, reactively responding to illness, to that of a proactive approach to health and wellness, providing care closer to home. We must strive wherever possible to shift the curve from high-cost reactive and bed based care to care that is preventive, proactive and based closer to people s homes, focusing as much on wellness as on responding to illness. Oliver et al. (2014) The King s Fund 9 This cultural shift promotes the need for proactive and preventative care through integrated services to meet the needs of the individual and their carers in line with the House of Care framework. 16

17 2.1.5 The Better Care Fund The Better Care Fund offers a real opportunity to transform local services by bringing resources together to lay the foundations for a much more integrated system of health and social care whilst delivering at scale and pace. The Better Care Fund shares this QGD s underlying principle of delivering the right care, in the right place, at the right time, including the expansion of care in community, out of hospital settings. The Better Care Fund: A single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities. Local Government Association, NHS England (2013) 10 In order to implement this quality guidance document across Wessex we need to work across health and social care to influence the scale and pace of change through the Better Care Fund. 2.2 Local Wessex context During this review it was evident that both nationally and locally there are areas of excellent provision of rehabilitation, reablement and recovery but with varying levels of adoption and dissemination. It was equally evident that there is also a lack of awareness of what services are available at a service user, provider and commissioning level. Across Wessex there is currently variable provision and different models of rehabilitation, reablement and recovery service with limited data available. Traditionally, both nationally and locally, there has been a focus on patient pathways but this is predominantly for the delivery of acute health and care services and specialist rehabilitation. As is clear from national directives there is a need to improve integration of services and care within the community to meet the ongoing needs of individuals with a variety of conditions. 17

18 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document 2. NATIONAL CONTEXT Diagnosis/ Acute Admission Community LTC management In-patient Rehabilitation Community Rehabilitation Figure 5: Focus of the Quality Guidance Document Stakeholder engagement and events In order to focus this area of work the Wessex Strategic Clinical Network has proactively engaged with a wide variety of stakeholders across health, social care and the third sector including commissioners, providers, patients and carers. The aim of our stakeholder engagement is to provide appropriate channels of communication and information so that every stakeholder is both empowered to contribute to the process but also takes ownership for the implementation of change. The steering group was created in November 2013 to oversee the rehabilitation programme of work with regional representation from all stakeholder groups.

19 In March 2014 a formal stakeholder event was successfully held, attended by 85 representatives patients, carers, CCG commissioners, local authority and the third sector from across Wessex. The event was held to gain agreement on the development of the rehabilitation, reablement and recovery quality guidance document for Wessex going forward and also gain commitment to deliver the rehabilitation, reablement and recovery work programme. Four key quality priority areas were identified and agreed across the Wessex SCN at this event: 1. Movement out of hospital 2. Accessing services (pathways) 3. Supported self-management 4. Quality outcome measures and key performance indicators (KPIs) Over the past 6 months further stakeholder engagement meetings and workshops have taken place to develop the QGD around the priority areas. 2.4 Key messages from Wessex stakeholders There have been some key messages that have resonated throughout the stakeholder engagement process. These represent an agreed minimum to improve the rehabilitation, reablement and recovery experience for patients, carers and professionals in Wessex. 1. There should be a single point of access for patients, carers and professionals to access services within their locality. 2. There should be a single point of contact a care navigator or key worker to coordinate the discharge process, accessing services and facilitating supported self-management. 3. Every person should have a health and social care plan on discharge from hospital, this should be updated as the individual s needs change and as the person progresses from supported self-management to selfmanagement this should progress to become a wellbeing plan with the person taking ownership. 4. Rehabilitation, reablement and recovery should be holistic encompassing all the needs of the individual health, psychological and social. FOOTNOTES 4 NHS England Mandate : 5 Department of Health (2012) The NHS Outcomes Framework Coulter A., Roberts S., Dixon A. (2013) Delivering better services for people with long-term conditions: Building the house of care. The King s Fund Oliver D., Foot C., Humphries R. (2014) Making our health and care systems fit for an ageing population. The King s Fund 10 Local Government Association, NHS England (2013). Statement on the health and social care Integration Transformation Fund [online]. Available at: HYPERLINK

20 Wessex Rehabilitation, Reablement and Recovery Quality Guidance Document 3. WESSEX REHABILITATION, REABLEMENT AND RECOVERY PRINCIPLES Through the series of stakeholder engagement events the following principles were identified and agreed for Wessex: 20 Parity of esteem: l The ethos of parity of esteem should underpin all service delivery ensuring equity for the mental health and physical health needs for all people. Promotion of lifestyle changes: l Lifestyle changes should be promoted to increase health, wellbeing and quality of life. l Professionals should ensure that people have the skills and support to improve their wellbeing and enable them to be independent in their own homes for as long as possible. l It is acknowledged that people have differing capacity to selfmanage but where appropriate each person is encouraged and supported to take ownership of their own care. l Personal choice and the role of personal health budgets should be promoted. Partnership working: l Individuals and professionals should work together in collaboration, instilling the ethos of shared care and shared decision making. l Professionals and organisations should work with individuals and their families and support carers. l A culture of integrated working should be promoted incorporating collaboration between services across health, social care and the third sector. l There should be clear communication links with the ability to share information across services (where appropriate). Development of the workforce: l The workforce should be focused on achieving a person s maximum potential and this should be incorporated into regular training and education. l The workforce should be suitably trained to meet the needs of patients with increasingly complex presentations. This will require generic and specialist community provision. Access to services: l There should be timely access to services including early intervention and re-access. l Services should have a single point of access for patients, carers and professionals to access services in their locality. l Services should have a single point of contact such as a care co-ordinator or navigator role. l Length of input from a service and access back into services should be based on need rather than time. Embedding goal setting as standard practice: l Goal setting should be used as standard treatment where hopes and goals are set collaboratively between the person and the service. Health and social care plan: l Each person should have a visible health and social care plan encompassing their rehabilitation, reablement, recovery and wellbeing needs. l Rehabilitation, reablement and recovery and the resulting individualised plan should be holistic encompassing all the needs of the patient health, psychological and social. l People should have control of their own health information/records. Service review and evaluation: l Key performance indicators and outcomes should be agreed between commissioners and providers to demonstrate patient outcomes appropriate to the given service. l In addition to activity figures, services should be regularly evaluated against this QGD s quality requirements to drive continuous service improvement.