South Gloucestershire proposed model of care

Transcription

1 South Gloucestershire proposed model of care

2 Contents Page 1 Executive Summary 4 2 Introduction 6 3 Process to design a new service model for rehabilitation 6 4 Changes proposed 7 5 Next steps 14 Appendix 1: Determining the Requirement for Non-Acute Beds Proposed Methodology Appendix 2: Summary of the current rehabilitation and reablement services currently provided in North Somerset Appendix 3: Avon I&MT Consortium: Modelling of Future Demand (Rehabilitation Review: Report 1) Appendix 4: Attendees at 28 th February 2013 South Gloucestershire meeting to decide next steps in developing a rehabilitation and reablement model for South Gloucestershire Version no. 1.2 Status Final Author Luke Culverwell Approver Rehabilitation Project Board Date for approval/ 04 th March 2013 Agreed circulation of this version Public Page 2 of 39

3 Version Date Reviewer Comment /01/2013 Hayley Burton Skeleton Outline /01/2013 Luke Culverwell Initial draft /02/2013 Luke Culverwell Included local authority services following meeting with Rebecca Harrold, (SGC) /02/2013 Luke Culverwell Amendments following meeting with Cathy Timothy (NBT) /02/2013 Luke Culverwell Amendments to community and acute treatment and rehab following meetings with Jill Boot (NBT) and Debbie Davey (SGCHS). Included future developments section. Minor edit and proof /02/2013 Allison Griffiths Amendments to community health service descriptions /02/2013 Luke Culverwell Amendments from Guy Stenson (SGC) & Jill Boot (NBT) incorporated /02/2013 Luke Culverwell Amendments from Jill Boot (NBT) ref acute neuro services, Rebecca Harrold & Jon Shaw (SGC) ref reablement service, homecare service and changes to acute bed-base /03/2013 Luke Culverwell Included of detailed recommendations from stakeholders event 28/02/13. Included executive summary. Removed detail from current state section and reworked as a summary. (original detailed description of current state available as a separate paper from /03/2013 Luke Culverwell Inclusion of appendices 2 & 3 statement from Save Frenchay Hospital Group and clarifying note from Healthy Futures /03/2013 Luke Culverwell Minor amendments following review by Elizabeth Williams /03/2013 Luke Culverwell Amendments following Review by project board /03/2013 Elizabeth Williams Amendments following review by the Clinical Commissioning Membership Group and the Clinical Operational Executive meeting /03/2013 Luke Culverwell Attached disclaimer to current state section and final prep for publication Page 3 of 39

4 1. Executive Summary Having reviewed how rehabilitation, enablement and reablement services are currently provided three areas for improvement were highlighted and at an event on the 28 th February 2013 recommendations for addressing these areas were discussed. The below summarises the issues and recommendations made. Question 1 How can we improve collaboration between acute, community and local authority teams to deliver a seamless rehabilitation and reablement service? Recommendations 1. Commission an end-to-end rehabilitation and reablement pathway. This would allow commissioners to work together to control the strategic development of rehabilitation services and to improve the coordination of services. 2. Adopt an agreed approach to rehabilitation planning which allows all rehabilitation and reablement professionals to use a single set of paperwork and tools to create a personal rehabilitation plan for each patient which is reviewed, administered and updated by each team involved in the patient s journey. 3. Develop proposals to improve & extend the single point of access for intermediate care, community rehabilitation and local authority reablement and social care services. 4. Develop proposals for a shared approach to staff development which removes barriers to joint working, including co-training of therapy staff from different organisations and rotation of therapy staff between community, acute and local authority services. 5. Emphasise the importance of the BNSSG Connecting Care project delivering a shared electronic patient record. Question 2 How can we increase the capacity of community health services to enable more rehabilitation and reablement to take place in a community setting? Recommendations 1. Undertake an options appraisal of ways resource can be moved from the acute to the community setting without creating financial instability. This might include: Transferring funding to the community along with therapy staff to reduce cost pressures in the acute trusts. The larger community providers would then be required to undertake non-acute rehabilitation in the community and in hospital. Requiring acute trusts to provide more rehabilitation in a Page 4 of 39

5 community setting within the existing financial envelope e.g. through an expansion of early supported discharge services. 2. In line with national initiatives, unbundle HRG tariffs which include an element of rehabilitation so that the acute treatment and the rehabilitation can be delivered and funded separately. 3. Investigate local arrangements for funding rehabilitation which allow the money to follow the patient as they move between teams and venues of care, supporting rehabilitation and reablement in places other than an acute hospital. 4. Introduce tariff changes gradually over a number of years to allow acute trusts to manage the reduction in income safely. Agree an approach to tariff change and reallocation of resources which shares risk between NBT and commissioners. Question 3 How do non-acute beds fit into the future model of rehabilitation and reablement? What type of beds should be provided? Recommendations 1. Define the boundary between acute rehabilitation and non acute rehabilitation within each patient pathway, drawing in work undertaken by North Bristol Trust and agreed definitions of level of rehabilitation needs which have been developed in trauma and orthopaedics. 2. Undertake a snapshot audit of patients currently in all the BNSSG Hospitals to determine the dependency profiles of these patients and to ascertain the proportion of patients who require rehabilitation in a non-acute bed. 3. Recognise that the requirements for non-acute rehabilitation beds and non-acute beds used to manage other patient groups need to be considered separately, and that a model which permits more rehabilitation in patient s own homes will not necessarily reduce the latter bed requirement. 4. Define a methodology for calculating the type and number of non-acute rehabilitation beds and the number of interim beds required. 5. Create and assess options for the provision of non-acute rehabilitation and interim beds to meet identified need. 6. Reconcile resulting bed requirements to previous calculations/forecasts. 7. Assess options for impact on patient accessibility (care Page 5 of 39

6 close to home) and equality. These proposals were discussed at the South Gloucestershire Clinical Commissioning Group membership meeting on the 12th March 2013 and the South Gloucestershire Clinical Operational Executive meeting on the 19th March Both groups agreed with the direction of travel and were particularly supportive of the work to determine the requirements from non acute beds across Bristol, North Somerset and South Gloucestershire. For further information on the proposed methodology to be used to determine the requirements for non acute beds, please see Appendix 1. The next steps for the review is to establish a number of short life groups to take the proposals agreed forward, during March, April and May Introduction The Healthy Futures Rehabilitation and Reablement Project aims to agree the future models of rehabilitation services that will operate across Bristol, North Somerset and South Gloucestershire. In the first phase of the project (Project Initiation) two workstreams were set up with the purpose of describing what rehabilitation, enablement and reablement services are currently provided in both the acute and community settings for each of the three Bristol, North Somerset and South Gloucestershire (BNSSG) areas. A summary of the current state is described in Appendix 2 of this document. Section 4 of this document describes proposed improvements to current services in South Gloucestershire. For details of services currently provided in North Somerset and Bristol please refer to documents entitled North Somerset Rehabilitation Current State and Bristol Rehabilitation Current State. Modelling and analysis work has been undertaken by the Chief Statistician at Avon IM&T in support of the BNSSG Review of Rehabilitation Services. The report in Appendix 3 highlights the issues which inform the review of rehabilitation services and are of relevance in determining the development of future service models. 3. Process to design a new service model for rehabilitation As part of the second phase of the project (Designing Service Models) a Design and Describe event was held on the 11 th January 2013 and attended by over 50 key stakeholders. This included representatives from South Gloucestershire Clinical Commissioning Group, South Gloucestershire Community Health Services, South Gloucestershire Council and North Bristol NHS Trust and South Gloucestershire Local Involvement Network. They worked together to start designing a future model of care for rehabilitation in South Gloucestershire, which builds on existing services and developments in rehabilitation and reablement. At the event two other groups of stakeholders from Bristol and North Somerset simultaneously designed future models of care for rehabilitation in each respective area. The three outputs of the event have since been drawn together to produce a high level model of care for rehabilitation services across Bristol, North Somerset and South Gloucestershire (BNSSG) (Figure 1). Page 6 of 39

7 A further half day workshop took place on the 28 th February 2013 and was attended by the key South Gloucestershire stakeholders, see Appendix 4 for details. The aim of this event was to focus on agreeing a more detailed system wide approach to rehabilitation and reablement in South Gloucestershire, based on the high level BNSSG model. 4. Changes proposed Whilst collecting information on the current state described above a wide range of stakeholders were asked how services could be improved and the following priority areas were highlighted: A need to improve collaboration between acute, local authority and community health teams. A need to create additional community rehabilitation and reablement capacity. A need to understand the place of non-acute beds in the proposed model of care. A meeting with all the key stakeholders within South Gloucestershire was held on the 28 th February, 2013 (see Appendix 1 for a list of those present) and the following recommendations were agreed:- Question 1 How can we improve collaboration between acute, community and local authority teams to deliver a seamless rehabilitation and reablement service? Page 7 of 39

8 Recommendations 1. Commission an end-to-end rehabilitation and reablement pathway. This would allow commissioners to regain control over the strategic development of rehabilitation services and to coordinate services which have hitherto emerged on an ad-hoc basis. 2. Adopt an agreed approach to rehabilitation planning which allows all rehabilitation and reablement professionals to use a single set of paperwork and tools to create a personal rehabilitation prescription for each patient which is reviewed, administered and updated by each team involved in the patient s journey. 3. Develop proposals to improve & develop the single point of access for intermediate care, community rehabilitation and local authority reablement and social care services. 4. Develop proposals for a shared approach to staff development which removes barriers to joint working, including co-training of therapy staff from different organisations and rotation of therapy staff between community, acute and local authority services. 5. Emphasise the importance of the BNSSG Connecting Care project delivering a shared electronic patient record. Discussion & background Governing principle: We need to commission rehabilitation and reablement as a coherent whole, not just as an add-on for acute treatments. A shared approach to rehabilitation and reablement planning is required, with all therapy staff using the same agreed assessment tools and accepting the validity of other professionals assessments and planning. The group discussed the suggestion that there should be a single assessment of patient needs. It was agreed that this was not the best approach and that all patients should receive multiple assessments from appropriate health and social care professionals as required. However, all assessments and all rehabilitation planning should be recorded in a rehabilitation prescription which would follow the patient throughout their journey, crossing organisational and team boundaries. The rehabilitation prescription should document the plan agreed between the patient and all care providers involved in delivery, and it should be possible for a rehabilitation or reablement worker to pick up this document at any stage and gain an immediate understanding of how the patient s rehabilitation plan had developed and what the next steps were. The group heard that this approach had been successfully used with major trauma patients at NBT, who were repatriated to their local hospitals along with a rehabilitation plan. It was noted that there was a need for caution with terminology Page 8 of 39

9 used to describe this approach as single assessment, shared assessment and common assessment are all terms which have been applied to previous approaches which were designed to serve the needs of the system rather than the patient. The group discussed the use of individual person profiles which collected information about personal preferences, lifestyle and values in a single place. It was agreed that this should form a core component of the proposed rehabilitation description. The group discussed the suggestion that commissioners should explicitly commission an end-to-end rehabilitation and reablement pathway, which clearly defines a specification for rehabilitation and reablement services. This would need to describe in detail the pathways for a large number of conditions. Many existing rehabilitation and reablement services and practices have developed organically, often to serve the need of a specific medical specialty to maintain patient throughput rather than the needs of the patient. The proposed approach would allow commissioners to take control of the strategic development of rehabilitation and reablement services and to coordinate this across all areas of provision. It would require commissioners to explicitly consider the requirement for rehabilitation and reablement provision when commissioning other services. It was noted that this approach to commissioning would fit with the above proposal for a shared rehabilitation plan which would cut across organisation boundaries. It was also noted that this approach would support efforts to move more rehabilitation from acute to community settings by allowing explicit commissioning of acute and non-acute rehabilitation. However, detailed work to unbundle rehabilitation monies form existing tariffs would be required to enable this. The group briefly considered whether there was a case for recommending integration between acute/community or health/social care teams. 4 members felt that integration was unnecessary, 2 members favoured physical integration and the remaining 4 members felt that virtual integration through mechanisms such as shared resources, pooled budgets or joint posts was desirable. At this stage, the group made no recommendation in this regard, and it was agreed that developing joint working was more important than formal integration of procedures or functions. The group recognised that many of the current difficulties with joint working relate to a lack of trust and understanding between teams Page 9 of 39

10 based in different organisations, difficulties sharing records electronically, and complicated referral processes and agreed, without debate, to recommend measures to address these problems. Question 2 How can we increase the capacity of community health services to enable more rehabilitation and reablement to take place in a community setting? Recommendations 1. Undertake an options appraisal of ways resource can be moved from the acute to the community setting without creating financial instability. This might include: Transferring funding to the community along with therapy staff to reduce cost pressures in the acute trusts. The larger community providers would then be required to undertake non-acute rehabilitation in the community and in hospital. Requiring acute trusts to provide more rehabilitation in a community setting within the existing financial envelope e.g. through an expansion of early supported discharge services. 2. Unbundle HRG tariffs which include an element of rehabilitation so that the acute treatment and the rehabilitation can be delivered and funded separately. 3. Investigate local arrangements for funding rehabilitation which allow the money to follow the patient as they move between teams and venues of care, supporting rehabilitation and reablement in places other than an acute hospital. 4. Introduce any tariff changes gradually to allow acute trusts to manage the reduction in income safely. Agree an approach to tariff change and reallocation of resources which shares risk between NBT and commissioners. Discussion & background Governing principle: Community rehabilitation needs to be resourced appropriately by ensuring that resources (either money or staff) are moved into the community alongside work. We need to find a way of transferring resources which minimises the risk of destabilising the local health economy. Members representing community health services explained that investment in community rehabilitation was shrinking whilst expectations of the amount of rehabilitation the community should deliver were growing. It was accepted that there are efficiencies to be released from community service provision, but that commissioners needed to recognise that increased resource Page 10 of 39

11 would be needed to meet growing demand. It was also noted that if patients are to leave hospital earlier under the new model of care they may have higher dependency than the current community caseload, increasing the pressure on resources further. The group agreed that where work was moved from acute trusts into the community, resources should also move. This could be effected by transferring funding or staff from NBT to South Gloucestershire Community Health, or by maintaining existing levels of funding and staffing within NBT, but requiring the trust to use this resource to deliver a greater proportion of rehabilitation in the community. The group discussed two options: 1. Basing therapy staff (and funding) in the community and increasing the amount of in-reach work which those teams undertake, providing rehabilitation to patients on hospital wards. 2. Increasing use of Early Supported Discharge (ESD) whereby specialist hospital therapy teams visit patients in their own homes after discharge to provide an intensive course of rehabilitation. The group agreed that in-reach provision of rehabilitation to inpatients worked well for patients with complex conditions who were already known to community health services, and was effective in facilitating discharge. For other patients with specialist rehabilitation needs who may also require some clinical supervision from a hospital consultant (e.g. stroke patients), ESD remains the preferred option and this could be adapted to other conditions. It was noted that from a commissioning perspective, ESD did not reduce costs as the savings were realised by the acute trust and were reinvested in acute services. The group considered that expanded use of ESD would need to be supported by a payment framework which allowed the resulting savings to be reinvested in developing community capacity. It was explained to the group that in some cases where patients receive rehabilitation in an acute setting, commissioners pay for this activity twice. Once through a rehabilitation bed day tariff which is paid for each day the patient is receiving rehabilitation, and once through the HRG tariff for the condition which the patient is being treated for, a proportion of which is intended to cover the cost of rehabilitation. The group agreed that there is a need for HRG tariffs to be unbundled so that the element intended to cover acute medical treatment and the element intended to cover rehabilitation can be separated. This would allow funding to follow the patient, allowing greater choice and supporting increased rehabilitation in the Page 11 of 39

12 community. The group agreed that it was necessary to find a way of unbundling the tariff and reallocating these funds which did not destabilise the local health economy. In order for this to work, there needed to be a genuine agreement about sharing financial risk associated with disinvestment from the acute sector. It was suggested that this may take the form of a percentage reduction in acute rehabilitation spend over a number of years, rather than a step-change in tariff. Question How do non-acute beds fit into the future model of rehabilitation and reablement? What type of beds should be provided? Recommendations 1. Define the boundary between acute rehabilitation and non acute rehabilitation within each patient pathway, drawing in work undertaken by North Bristol Trust and agreed definitions of level of rehabilitation needs which have been developed in trauma and orthopaedics. 2. Undertake a snapshot audit of South Gloucestershire patients currently in Frenchay and Southmead Hospitals to determine the dependency profiles of these patients and to ascertain the proportion of patients who require rehabilitation in a non-acute bed. 3. Recognise that the requirements for non-acute rehabilitation beds and non-acute beds used to manage other patient groups need to be considered separately, and that a model which permits more rehabilitation in patient s own homes will not necessarily reduce the latter bed requirement. 4. Define a methodology for calculating the type and number of non-acute rehabilitation beds and the number of interim beds required. 5. Create and assess options for the provision of non-acute rehabilitation and interim beds to meet identified need. 6. Reconcile resulting bed requirements to previous calculations/forecasts. 7. Assess options for impact on patient accessibility (care close to home) and equality. Discussion & background Governing principle: We cannot make a decision about the number of non-acute beds required until we have an accurate understanding of who is occupying beds in acute hospitals and how many of these patients are appropriate for rehabilitation in a bedded facility. Page 12 of 39

13 The group discussed two rehabilitation bed models which are currently operational in South Gloucestershire: Beds are purchased from local care homes for rehabilitation and reablement. Patients receive physiotherapy input from care home staff, and intensive rehabilitation from community physiotherapists and occupational therapists who visit the patient in the care home. Beds are provided at Thornbury Community Hospital for patients with unpredictable health needs as well as for patients with intensive or complex rehabilitation needs. Medical cover is provided by Thornbury GPs and care is provided by a multidisciplinary team of nursing and therapy staff. It was noted that patient feedback about both models is very positive, but that Thornbury Community Hospital is not a costeffective bed model, with each bed costing roughly the same as a bed in an acute hospital. The group heard from clinical members that some acute rehabilitation needed to take place in hospital because of the infrastructure required, but that non-acute rehabilitation could take place in any venue where there is sufficiently intensive rehabilitation and reablement input. In cases where a patient is medically fit but requires ongoing rehabilitation in a bedded facility, there is no inherent requirement for medical cover, and these beds could be provided in care homes or units where care is supported by integrated teams.. Save Frenchay Hospital Group (SFHG) expressed a concern that without an appropriate level of community hospital provision to manage patients who were not yet fit for discharge home, acute hospitals in South Gloucestershire would be unsafe. SFHG were particularly concerned that this would become more apparent as moves towards 7-day working increased the rate of acute hospital throughput. The meeting recognised that rehabilitation patients were not the only patient group requiring a period in a non-acute bed. It was agreed that the requirement for non-acute beds specifically for rehabilitation and reablement is an entirely separate issue from the requirement for non-acute step-up or step-down beds for patients who require intermediate care, have an extended post-acute recovery period or have on-going medical or nursing needs. The requirement for non-rehabilitation community beds would need to be specifically modelled, albeit that this question is outside the remit of the Rehabilitation Review. Page 13 of 39

14 SFHG produced a written statement of their position on community bed provision and requested that this be included with the minutes of the meeting (Appendix 2). A clarifying note on this from the Healthy Futures Project Team has been attached at Appendix 3. The group agreed that in order to determine how many non-acute rehabilitation beds were required, it was necessary to develop a clear definition for acute rehabilitation which must take place in a hospital, and non-acute rehabilitation which nonetheless needs to take place in a non-medicalised bed. Work has already been done to define a hierarchy of rehabilitation needs for trauma and orthopaedic patients as part of Southmead Hospital s designation as a regional major trauma centre, and NBT is currently undertaking work to map rehabilitation pathways for all patient groups. This should be taken as a starting point for the above proposal. The group discussed undertaking a multidisciplinary snapshot audit of patients in hospitals in BNSSG on a given day to determine the dependency profile of these patients and to ascertain the following, according to the agreed definition of medical fitness and readiness for non-acute rehabilitation: 1. % patients who can go home to receive rehabilitation 2. % patients who need to continue rehabilitation a bedded unit, but who do not require medical cover 3. % patients who need to continue rehabilitation in hospital This work would inform decisions about the number of community and acute beds required. There was a view that a useful element of this BNSSG snap shot audit would be the fact that everyone was using the same criteria. 6. Next steps The Rehabilitation Project Board has agreed to establish a number of short life groups to take the following pieces of work forward:- Conduct a snapshot audit Define methodology and process for agreeing the type and number of non acute beds within BNSSG Conduct an option appraisal exercise to review ways of moving rehabilitation resources from the acute hospitals to the community Share paperwork, processes, rehabilitation plans and patient profiles Conduct an option appraisal exercise relating to the implementation of a Care Coordinator role Use the feedback from the Project Board to improve the rehabilitation and reablement baseline data Investigate how to commission an end to end rehabilitation/reablement pathway Page 14 of 39

15 Improve and develop the joint health and social care single point of access in South Gloucestershire and Bristol Investigate options for how to integrate all those working on rehabilitation within health and social care into a single pathway in Bristol Investigate how to provide community access to diagnostics and a Consultant opinion within Bristol Review section 2 and 5 procedures to design a system that facilitates timely discharge and enables greater collaboration between hospital and community staff in Bristol Investigate how best to resolve the lack of domiciliary care at peak times in North Somerset. The time scale for this more detailed work is from March to May Page 15 of 39

16 Appendix 1 Determining the Requirement for Non-Acute Beds Proposed Methodology 1. Background The Bristol, North Somerset and South Gloucestershire (BNSSG) Rehabilitation Review has made progress towards developing a new model of care which envisages a shift in rehabilitation provision and resource from acute hospitals to community settings, including non-acute community beds and rehabilitation and reablement delivered in patients own homes with additional care and support where necessary. This shift in rehabilitation provision recognises the importance of promoting independence and delivering local services, whilst also focusing acute services on patients with acute medical and rehabilitation needs. The potential for changes in the location of services and the implications for the number of acute and non-acute beds provided is of interest to provider trusts, which will take this into account when planning changes to their bed-base, commissioners, who are engaged in deciding the appropriate level of future community bed provision and many local stakeholders including patients, carers and local authorities. The purpose of this paper is to set out a proposed methodology for defining: The number of non-acute beds which will be required in each CCG area under the new model for care for rehabilitation The type of non-acute beds which need to be provided The framework for making a decision between different options for bed provision. A by-product of this methodology will be to define: The amount of activity which will be transferred from acute providers to the community and the number of acute beds which can be reassigned or decommissioned as a consequence. This paper will focus on the methodology being applied to the modelling of beds, however parallel activities need to be undertaken in modelling the capacity of those community, social care and primary care services which would be impacted by any changes in the model of care for rehabilitation services. 2. Community Beds in BNSSG Current Position Current plans for 2014/15 include provision of 180 community hospital beds across BNSSG, broken down as follows: 68 at Frenchay Hospital 60 at South Bristol Community Hospital 32 at Southmead Community Hospital 20 at Clevedon Community Hospital Page 16 of 39

17 This provision is deemed both necessary and sufficient to meet demand in this period. However, this is predicated on North Bristol Trust achieving the ambitious length of stay reductions required to operate wholly within its reduced acute bed-base following the opening of the new Southmead Hospital development. Additionally, this provision has not taken into account the potential of the Rehabilitation Review to change the way in which services are provided and potentially reduce the need for rehabilitation beds. It should also be noted that demand for rehabilitation services is projected to increase over the next 6 years by an average of 1.8% per annum across the whole of BNSSG due to the ageing population. 3. Defining the Number of Non-Acute Beds Required 3.1. Establishing the basic level of provision required In March & April 2013, a short-life working group will be established to plan and undertake a snapshot utilisation audit on every bed in each of the acute and community hospitals across BNSSG, namely: Southmead Hospital Frenchay Hospital Bristol Royal Infirmary Weston General Hospital Clevedon Community Hospital South Bristol Community Hospital Thornbury Community Hospital This will be repeated as necessary to produce a picture of average bed utilisation which can be used to identify the proportion of patients who: Are appropriate for an acute bed Could more appropriately be managed in a non-acute bed Could more appropriately be managed at home (or their normal place of residence) with adequate provision Have no medical or therapeutic need but who nonetheless need to be managed in a bedded environment because they are unsafe to return home or require longer term support and are awaiting a transfer of care. In order to achieve this it will be necessary for acute and community clinicians and therapists to agree parallel hierarchies of both rehabilitation and medical need, with thresholds and definitions for non-acute, sub-acute and acute care which should be delivered in the community, in a non-acute bed and in an acute bed respectively, as illustrated below: Acute Medical Needs Acute Rehabilitation Needs Page 17 of 39

18 Sub-Acute Medical Needs Sub-Acute Rehabilitation Needs Non-Acute Medical Needs Non-Acute Rehabilitation Needs No Medical Needs No Rehabilitation Needs An audit tool will be developed which will allow a multidisciplinary team to assess every patient s level of need according to both of these scales. The detailed audit methodology will be set out in a separate paper, but the below matrix illustrates how each patient s assessed levels of medical and rehabilitation need allows a determination to be made about the appropriate venue for treatment: Acute Rehabilitation Needs Sub-Acute Rehabilitation Needs Non-Acute Rehabilitation Needs No Rehabilitation Needs Acute Medical Needs Acute Bed Acute Bed Acute Bed Acute Bed Sub-Acute Medical Needs Acute Bed Non-Acute Bed Non-Acute Bed Non-Acute Bed Non-Acute Medical Needs Acute Bed Non-Acute Bed Community Provision Community Provision No Medical Needs Acute Bed Non-Acute Bed Community Provision Interim Beds (where other circumstances necessitate use of a bed) Acute Beds represent the residual requirement for beds in acute hospitals after all patients who could more appropriately be treated elsewhere have been removed from consideration. Community provision represents the potential to decrease the acute-bed base by removing activity from hospital and providing this in patient s own homes or on an outpatient basis. Interim Beds represent the potential to decrease the acute bed-base in the medium to long term if wider-reaching system issues which are preventing discharge or transfer of care can be resolved. However, in the short term it is likely that there will need to be some provision of interim beds, where these patients can be safely managed pending transfer of care. Page 18 of 39

19 Non-Acute Beds represent the potential to decrease the acute bed base if this is matched by a corresponding increase in bed provision outside of the acute setting. It should be noted that non-acute beds further subdivide into Non-acute beds for rehabilitation Non-acute beds for purposes other than rehabilitation (including recovery, step-up/step-down or intermediate care and the management of patients with sub-acute or near-acute medical needs who are nonetheless medically stable) The requirement for both types of bed will be identified by the audit, but provision of non-acute beds for purposes other than rehabilitation will not be explicitly considered as part of the Rehabilitation Review although commissioners may wish to use this information to take commissioning of these beds forward outside the context of the review Adjusting the basic level of provision for growth & efficiencies The required number of acute and non-acute rehabilitation beds identified above will need to be adjusted to reflect both the projected growth in rehabilitation activity, and the potential for redesigned rehabilitation pathways to shorten patients length of stay and therefore reduce bed requirements. Growth in rehabilitation activity due to the changing demographic structure of the population can be modelled as below: South Gloucestershire North Somerset Bristol 3.0% per annum over the next 6 years 3.3% per annum over the next 6 years 0.6% per annum over the next 6 years The potential for improved rehabilitation length of stay is more difficult to model, although as an illustration, a one-day reduction in rehabilitation length of stay across BNSSG would reduce required bed provision by 9 beds. Further work needs to be undertaken to define this methodology for inclusion in future versions of this report. 4. Defining the Type of Non-Acute Beds Required Once the required number of non-acute rehabilitation beds has been identified, an options creation and appraisal exercise will be undertaken to produce suggestions for how this requirement could be met in each of the three CCG areas. Definitions of acute, sub-acute and non-acute medical and rehabilitation thresholds outlined above at 5.1 will contain a detailed description of the level of medical, nursing and therapy input which is required at each stage. These will be agreed by clinicians and therapists working within community and acute providers and should form the basis for the models suggested, taking into account evidence for alternative non-acute bed models in use elsewhere. Page 19 of 39

20 Work undertaken by South Gloucestershire Community Health Services in March 2012 to define a range of options for the provision of rehabilitation illustrates some of the possible models of bed provision: Rehabilitation in a traditional community hospital where medical cover may be provided by a consultant or staff-grade doctor. Rehabilitation in multidisciplinary rehab and reablement centres where medical cover may be provided by a GP, with the option to escalate patients for consideration by a staff grade specialty doctor or consultant. Rehabilitation in nurse-led or therapist-led facilities for patients who require minimal medical supervision. Rehabilitation in care homes with nursing and therapy input provided by the care home staff and intensive rehabilitation input provided by visiting hospital or community therapists. Rehabilitation in residential homes for patients who are unable to mobilise without assistance but who do not require nursing. Rehabilitation provided to patients in their own homes via an early supported discharge or virtual ward model under which an enhanced level of medical support is provided by GPs and rehabilitation and nursing input is provided by hospital or community multidisciplinary teams. These are in addition to the Acute Hospital bed, where rehabilitation also takes place. In order to allow commissioners to assess the relative costs and benefits of the suggested models, a detailed appraisal of each model will be undertaken, which will take into consideration the following: The ability of the model to deliver sufficiently intense therapy input to realise the aim of maximising the rehabilitative value of the patient s stay. Quality of service provided and the ability of the model to deliver the patient choice and patient experience agendas. The ability of the model to deliver the care closer to home agenda Flexibility of the model, both to satisfy spikes in demand and to scale down bed provision and costs during periods of low demand. An assessment of the impact of the model on equality of access. Feasibility of delivering the model in each of the CCG areas in light of existing local service provision and market landscape, including consideration of whether existing infrastructure can accommodate the model. Financial cost of the proposed model, both in terms of capital and revenue spend required. In order to assess value for money and ensure comparability between different models, this will need to be considered from two perspectives: o Cost per bed o Cost per patient Page 20 of 39

21 Appendix 2 Summary of current rehabilitation, enablement and reablement services in South Gloucestershire Disclaimer: This section sets out a high-level overview of how rehabilitation, reablement and enablement services are currently provided in South Gloucestershire and how those services interact. Every effort has been made to ensure accuracy, but for the sake of clarity descriptions of some services have been simplified and generalisations may have been made. This section is not a definitive or contractual specification for the services described and patients may not be able to access services in the way described where this is not clinically appropriate or where they do not meet the access criteria for services. To enable us to agree on how rehabilitation services in South Gloucestershire could be improved we needed a detailed understanding of the current state. A summary description is set out in this section. Detailed descriptions can be found in a separate Current State paper which can be downloaded from the Healthy Futures website ( or obtained in hard copy by ing healthy.futures@bristol.nhs.uk or telephoning Prevention and maintenance Prevention and maintenance has been identified as essential to long-term patient care. There has been a shift in focus within the NHS and social care, from sickness and cure to wellness and prevention, which is reflected in the fact that the management of long term medical conditions and other issues relating to old age are being given a high priority. This project will not be focussing on preventative services, there is however another Healthy Futures project which is focusing on improving this part of patient care. There are a wide range of services in South Gloucestershire relevant to rehabilitation, which aim to keep people healthy and independent, including: Telehealth: Bristol Community Health supplies remote monitoring devices to patients living in South Gloucestershire with COPD or Heart Failure. Patients are shown how to use the devices in their own home. Daily recordings are sent to a named South Gloucestershire community clinician through a secure IT network to enable monitoring of the patient s condition. Page 21 of 39

22 Anticipatory care planning: GP Practices work with community matron teams to develop anticipatory care plans for patients with complex and long term conditions. Some patients who are undergoing elective orthopaedic or vascular surgery will receive a preoperative occupational health and physiotherapy assessment which will identify support needs in advance. Falls Prevention: A community-based falls service provides specialist physiotherapy to help people recover function following a fall, or to provide preventative physiotherapy to people at risk of falls. Well Aware: Patients can access an online directory and telephone advice detailing health and social care services available in South Gloucestershire. Voluntary / Third Sector organisations in South Gloucestershire: There are a number of organisations which promote independent living and provide support and guidance to residents of south Gloucestershire who have a rehabilitation or reablement need. The following is not an exhaustive list: o WE Care & Repair o Living (previously the Disabled Living Centre) o British Red Cross o Bristol Area Stroke Foundation o Merlin Housing Society o Action for Blind People o Age UK Diabetes and Nutrition service: provides free courses within the community to help people with diabetes manage their condition. The courses available are for: o Adults newly diagnosed with type 2 diabetes o Adults with type 2 diabetes and who use insulin o There are two courses for adults with type 1 diabetes, one looking at skills for life and the second looking at food freedom with insulin adjustment. Assistive Technology and Telecare: South Gloucestershire Council provides a range of telecare equipment to allow service users to remain safe at home, including temperature sensors, door exit alarms and panic alarms. Alerts raised by telecare equipment are received by a 24-hour monitoring centre which coordinates a response. (There is a small weekly charge for the rental of equipment.) Exercise on Prescription: Patients who have long term conditions which would benefit from regular exercise can be referred to South Gloucestershire Council s exercise on prescription scheme. The scheme aims to reduce the risk of a patient requiring urgent healthcare interventions as a result of their condition. Eligible patients receive an initial assessment by a fitness specialist who will coordinate and supervise a 12-week exercise programme. Pulmonary Rehabilitation: These are intensive courses of physiotherapy and exercise delivered in the community which are designed to help patients with breathing difficulties to improve their level of lung function, and to learn self management techniques. Page 22 of 39

23 Homecare Service: South Gloucestershire Council s homecare service assesses people s need for social and personal care both on a short term basis to recover from illness or injury, or to meet long term needs. Services are commissioned form independent providers. Patients undergo a financial assessment and may be required to make a contribution to the cost of care. Community Meals Service: South Gloucestershire Council provides hot and cold meals 7 days a week, including public holidays, for people who are unable to shop, prepare food or use an oven. This can be for a very short term if someone is recovering from illness or long term where there is an ongoing need. There is a charge for this service. 1.2 First point of contact Individuals enter the rehabilitation model when their health or social needs change. This change may be planned, such as going into hospital for a planned procedure, or it may be the result of a slow deterioration in a person s health, or a rapid deterioration resulting from illness or injury. If there is a change in need a patient or their carer may make first contact with the health service in one of the following ways: By calling NHS Direct (or NHS 111 from April 2013). By visiting a GP practice, or calling the out of hours GP service. By visiting the GP-led walk in centre in Kingswood By visiting a minor injuries unit at Southmead Hospital or Yate Health Centre. By visiting the emergency department at the Bristol Royal Infirmary or Frenchay Hospital. By calling 999 in a life threatening emergency. Low risk patients who have been triaged by a GWAS Emergency Care Practitioner may be diverted to South Gloucestershire Community Health s unplanned community rehab service where this is appropriate. 1.3 Assessment Phase Hospital Assessment & Diagnosis This document will focus on patients who access services provided by North Bristol NHS Trust; however it is acknowledged that some South Gloucestershire residents may use services provided by UH Bristol. These are described in the Bristol Rehabilitation Model document. REACT: This is an admission avoidance service located in the emergency department at Frenchay Hospital. The REACT service aims to maximise a patient s independence by identifying those who are suitable for the Community Rehabilitation Service and arranging home assessments from members of the team, preventing avoidable hospital admissions and premature admissions to residential and nursing homes. NBT assessment: Some patients who are undergoing elective surgery will receive a pre-operative occupational therapy assessment to identify rehabilitation requirements in advance and create a rehabilitation plan which will be reviewed after surgery to take account of any changed circumstances. Page 23 of 39

24 Patients who attend the emergency department receive emergency medical treatment and are then admitted either to Frenchay s Acute Assessment Unit (AAU), to ITU or to a specialty bed. AAU ITU and specialty wards each have a dedicated rehabilitation team and there are rehabilitation teams with specific responsibility for general medical wards Frenchay Day Hospital: The day hospital at Frenchay offers rapid access to diagnostics and senior review by a consultant geriatrician in order to reduce avoidable admissions and provide medical support for patients being managed in the community. Referrals are received from GPs and community teams. Community Referral, Assessment & Diagnosis Transfer of patients from hospital to community services: Ward staff have four main points of contact when making discharge arrangements: Social care assessment are arranged through a referral to the hospital s social work team for assessment. Community rehab, community nursing support, and discharge to Thornbury community hospital are arranged through the Joint Community Access Portal. Major adaptations to property and input from local authority occupational therapists is arranged through South Gloucestershire Council s adult care desk. South Gloucestershire Community Health s liaison team are based at Frenchay hospital and sit in on daily bed capacity meetings. The Community Liaison team pro-actively identify complex patients who are approaching discharge, and carry out an assessment of patient s needs to inform their community rehabilitation. Common Approach: This is a virtual single entry point for all urgent care services in South Gloucestershire. There are agreed protocols and pathways for the management and onward referral of all patients requiring urgent care. Telephone or face-to-face triage is undertaken and patients are streamed for same day GP or Minor Injuries Unit appointments, or are referred to social care or community health services as appropriate. Joint Community Assessment Portal (JCAP): There is a single point of entry into all South Gloucestershire Community Services which covers both the step-up and step-down elements, as well as managing the allocation of rehabilitation beds at Thornbury community hospital. The service is accessed through a single phone number. Other Rehabilitation services provided by South Gloucestershire Community Health: South Gloucestershire is administered as four localities, each with a central locality base. Routine and urgent referrals for district nursing, support from an integrated multidisciplinary care team, domiciliary physiotherapy, podiatry and the falls service are all made via the appropriate locality base. Page 24 of 39