A collaborative approach to. rehab, reablement, recovery, survivorship & prehab (rehab) in the SW

Transcription

1 A collaborative approach to rehab, reablement, recovery, survivorship & prehab (rehab) in the SW Ruth Hall, Quality Improvement Programme Manager SCN Stephen Illingworth, GP Clinical Lead (S Glos) April 2015

2 What are we going to cover? Function of the SW SCN Why this programme of work How we used the learning from S Glos SW pathway and principles How this is being implemented 2

3 SW SCN Map 3

4 NHS England South West Strategic Clinical Networks (SCN) Initiated in April 2013 What do they do? Support economies to improve health outcomes by connecting commissioners, providers, professionals, patients and the public Networks: 1) Cancer 2) Mental Health, Dementia & Neurology 3) Cardiovascular 4) Maternity & Children Cross cutting themes that work across all Networks above: Rehab, reablement, recovery, survivorship & prehab 4

5 Why rehab, reablement, recovery, survivorship & prehab? Aging population. Increasing numbers of patients with LTCs Increasing frailty. Overall financial challenge Over reliance on acute beds Above average lengths of stay Merger of acute hospitals in North Bristol Proposals for rehab beds at Frenchay unaffordable Help people to be less reliant on statutory services (acute beds too) A vision to reduce LoS and provide more rehab in the community Drive to promote independence and for personalisation & integration 5

6 Things we know: People are living longer and have increasingly complex needs - rarely have 1 medical condition Limited resources Examples of good care but not always joined up impact on system flow Poor co-ordination across health and health and social care People tell us the system doesn't work for them Inequity in provision in SW BUT enthusiasm to improve services & areas of excellent practice in SW 6

7 The S Glos experience Merger of acute hospitals in North Bristol Proposals for rehab beds at Frenchay unaffordable BNSSSG Healthy Futures Board - 3Rs review Extensive public & stakeholder engagement What matters to patients Audited rehab needs of inpatients 40% of people no longer need services of an acute bed High level model of care Implementation in 2 phases Re-commissioned community services Process will take a number of commissioning cycles 7

8 South Glos Refinement of BNSSG Model 8

9 Aim of the SCN work was to: To redesign rehab, reablement, recovery, survivorship & prehab services in South West to create a pathway which is focussed on Understanding the needs of people And provides: Safe, high quality care that reflects good practice and makes the best use of scarce resource Equity and consistency Transparency for patients & carers 9

10 How has the SW SCN delivered this programme? SW Project Group Champions & clinical lead Learn from forerunners in SW ie South Glos, Symphony, Pioneer Projects 2 day event 1 st and 2 nd July = outputs where pathway & principles Multi agency LA/Health/PH. Delivered commissioning advise to SW Oct 2014 Feb 15 Commissioners day to support how it is commissioner Finance paper to Dragons Den 10

11 11 DesignPrinciples 1 st andsingle pointof contact,referal, asesmentor diagnosis Joint/ colaborative asesmentwith theperson Acute/Comunity InpatientRehabPlan ComplexHomeRehabPlan HomeRehabPlan Definitions ProfesionalReviewandEvaluations Shared analysisof demandon thesystem for forecasting, prioritisation and inovation Discharge In-reach andoutreach DesiredIntegratedRehabilitationPathway HighLevelSumary PersonandCarerSelfReview,MonitoringandManagement Continuityofcareintransfer BEFOREMYREHAB Ihavehadanacute episodeandhaveben treatedforit or Ihavebendiagnosedor asesed or Ihavebencopingat homebutiamstartingto strugle.inedsome helptokepme independent and Idonothaveanycritical healthorsocialcare nedsnow Iwantounderstandboth myown,myfamily sand mycarer sroles Iwantounderstandhow thingsmightprogresin thefuture Myfamilyandmycarer wantheirneds considered AFTERMYREHAB Ifelincontrolofmy lifeagainandiam abletomakea contributiontothe thingsthatare importantome. Icanmanage matersbymyself/ withmycarer/ family/comunity.i havenofurtherned forformalsuport. IunderstandhowI mightprogresinthe future. Myfamily/carerfel thatheirnedshave benconsidered. Ifelrespectedand listenedtoandi knowhowtogethe righthelpinatimely fashionifinedit. Iunderstandboth myown,myfamily s andmycarer srole.

12 The person-centred rehabilitation lens Self-management Acute / community in-patient rehab plan Personal Complex home rehab plan First single POC Joint, collaborative assessment of need, options, choices, outcomes, incentives, management The person, their carer and family in their community Managed conclusion of formal rehabilitation care and support Rehab Plan Home rehab plan Re-assessment 12

13 South Glos gap analysis 13

14 Key Components of the Service: Multidisciplinary assessment at presentation Care plan (patient defined rehab goals) Service will be designed and resourced so that patients spend as little time in an acute bed in a hospital as is possible and are moved to a more appropriate rehab setting at the earliest opportunity Care co-ordinator/navigator who will provide a single point of contact for the patient and their carers while they are in receipt of the service 7/7 support for patients and carers Standard use of the rehabilitation complexity scale and the associated rehab flag Access for people living in the community Additional focus on prevention and on helping people understand how they can best manage their own conditions 14

15 What is the progress in the SW? 15

16 What is the progress in the SW? Strategic pathway & principles commissioning advice for all Health & Social Care Commissioners for 2015/16 Developing a generic business case Delivery via Integrated Personal Commissioning demonstrator status 16

17 What is the progress in the SW? Bottom up approach what people can do locally Making it real a case scenario developed by County Council OT: Mrs Jane Bond,49 yrs old. Works for Highways part time office based, diagnosis of MS 10 yrs ago. Lives with husband (who works full time lorry driver shifts and some overnights away) and daughter (12 yrs old). Still driving but finding this more difficult and feels unsafe. Lives in a 1930s 3 bedroomed semi detached owner occupied house in a village, 8 miles from nearest large town. Moved there 18 months ago. Gait effected, poor unsteady balance, particularly when tired. Some tremor in hands particularly, when tired. 17

18 Present Future Section in integrated pathway Jane visits GP as she is low in mood and concerned that she will need to give up her job as she gets so tired. She is also afraid of falling on the stairs at work 1st journey through pathway Possible provision of Meds GP recommends: Swimming - needs to do this AMs when less tired Pilates in village to strengthen core muscles and improve balance. Community support: Link in daughter to youth club in village Contact village church community to seek volunteer to support her accessing swimming Collaborative assessment Home rehab plan Jane reports improved feeling of confidence and generally feeling well and that her daughter is making friends in the village Outcome Jane visits her GP as she had developed an acute UTI Meds 2nd journey through pathway Referral for POC Community Nursing support to discuss and support continence management as though UTI cleared, Jane is now struggling with maintaining continence and is very concerned she will have an accident whilst away from the house. She is therefore afraid to go out and has been off sick from work as a result, she has lost confidence and motivation to complete daily living tasks at home. There is an impact on her role as mother and wife no longer confident to do weekly shop etc. Collaborative assessment 18

19 Present Future Section in integrated pathway Community Nurses refer to single POC identifying needs re: confidence with ADLs. In discussion with Jane to identify what goals she wishes to achieve - Jane agrees to a 6 week home rehab intervention support with personal care to increase confidence and OT and Physio :-. Fatigue management advice, equipment and exercises to improve strength and tolerance.. Jane also orders an ipad so she can shop on line for family weekly groceries. Community support: Shop in village puts her in touch with a retired IT teacher who agrees to visit her to teach her how to get the best from her technology! Jane is able to continue in her chosen roles within the family and the Collaborative assessment Home rehab plan Selfmanagement Outcome community following minimal support/intervention. Jane falls at home on the stairs and is taken to A and E and subsequently admitted. It is identified that she has sustained severe bruising and has another UTI. She is very worried about being away from home as her daughter is alone at home as her husband is away for work. She has no family nearby. Admission to A community rehab plan is put in place to support her early discharge this Part of acute includes a full joint/collaborative assessment with Jane to identify what she continuous hospital/daug wants to achieve/what it is important for her in her roles ( as mother/wife) assessment hter in short and her daily life. term care. Package of Clear goals are identified and there is a discussion with her regarding use care on of Direct Payments. Professional discharge review & inflexible in Jane fully involved in identifying what is important to her role as wife and evaluation = terms of mother able to use Direct Payment to pay for support to get Home rehab times and washed/dressed and get daughter ready for school, plan tasks. Outcome 19 3 rd journey through pathway Jane is able to save her energy for spending time with daughter after school and to enable her to continue to attend Pilates classes.

20 To summarise SW strategic pathway & principles Examples of how it is being implemented Requires local interpretation & championing The SCN can support localities It is difficult & will take time About cultural change in all organisations & people A lot of excellent practice & enthusiasm in the SW There is a national clinical director Supports the 5 Year Forward View 20

21 Thank you for listening Any questions? How can the SW SCN support you? How would you like to be involved and kept informed?