Improved quality of life and achieved optimum level of function.

Transcription

1 1. Population Needs 1.1 National/local context and evidence base The Romney Marsh Day Centre s Rehabilitation Unit and the Rehabilitation Services provided were designed, built and developed in partnership with the former East Kent Coastal Primary Care Trust (EKCPCT), Kent County Council, Adult Services (KCCAS) and the Romney Marsh Day Centre (RMDC). Funding for this project was agreed under a Section 75 agreement. The capital costs associated with the construction of the Rehabilitation Unit were funded by both RMDC and KCCAS with the EKCPCT agreeing to support the on-going revenue costs for the provision of Rehabilitation Services at the unit. Continuing funding from the Commissioner is specifically to pay for the employment by the provider of 2 (two) rehabilitation workers for 25 hours per week on a continuous basis. The Romney Marsh Day Centre s Rehabilitation Unit must offer swift access to local rehabilitation services, the Commissioner being mindful that the Romney Marsh is a large unique rural isolated area with poor transport facilities. 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with long-term X conditions Domain 3 Helping people to recover from episodes of ill-health or X following injury Domain 4 Ensuring people have a positive experience of care X Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm X 2.2 Local defined outcomes Improved quality of life and achieved optimum level of function. Reduced need for high level domiciliary care packages. Reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen. Reduced re-admissions to ICT. Achieve improved health & wellbeing for client group Support & achieve positive rehabilitation outcomes for clients within the local community. Supported timely hospital discharge and continuity of care within the community. 3. Scope 3.1 Aims and objectives of service Aims

2 To provide short term rehabilitation interventions within a local community based rehabilitation unit. Providing flexible individual rehabilitation therapy programmes following injury, illness or an exacerbation of an existing condition, which will assist in regaining physical abilities and the skills and confidence needed to enable clients to live as independently as possible in their own homes To provide integrated individualised flexible services for older people which result in meaningful improvement to their health and wellbeing and promote continuity of care to clients. Offer person centred flexible care in conjunction with the Intermediate Care Team (ICT) to facilitate health promotion through prevention and maintenance activities for older people in the local community. Offer improved access to local services enabling people living in the Romney Marsh area, a large unique rural isolated area with poor transport facilities to access services within their own community. To reduce readmission to ICT services through prevention and maintenance activities. Provide a local community based resource for the ICT to carry out treatments and to facilitate and improve team function. Secondary aims Be reactive to clients needs through client consultation and the development of graded progressive treatment programmes. To provide an effective value for money service offering local access to a community based rehabilitation unit. Ensure liaison with local health and social care professional to ensure best health care outcomes for individuals. Objectives Provide assessment of individuals identified for the service. Ensure effective communication is maintained with the general practitioners, clients, relatives and other agencies. Provide flexible programmes of support, care and rehabilitation to fit individual needs. Agree with individuals, achievable aims for their rehabilitation, carrying out regular reviews and keep the individual informed of their progress. Treat clients, their relatives and carers with regard to dignity, privacy and respect for all cultural and personal beliefs. Offer a preventative service that enables clients to access structured group activities designed to assist with falls prevention, maintaining everyday living skills, promoting health & wellbeing and reducing social isolation. Comply with all legislation, policies and procedures as well as professional codes of conduct and professional practice. Improve access to community based services. Provide person centred treatment options.

3 Promote faster recovery. Prevent unnecessary acute hospital admissions, 3.2 Service description/care pathway The Provider will work with Kent Community Healthcare Trust s (KCHCT) Intermediate Care Team and will provide individual therapy programmes following illness or injury which must assist in regaining physical abilities and the skills and confidence needed to enable patients to live as independently as possible in their own homes. To employ and pay 50 hours of Rehabilitation Workers per week the Provider to employ 2 suitably qualified individuals. To provide day to day management of the Rehabilitation Workers To ensure that the Rehabilitation Workers are appropriately qualified and trained To ensure that the Rehabilitation Workers are Disclosure and Barring Service checked To provide a facility which meets all health and safety standards for all NHS in reach clinicians Keep a record of client contacts by Rehabilitation Workers Maintain a risk register for the rehabilitation unit Provide details of any complaints made against the Rehabilitation Workers

4 Romney Marsh Day Centre Rehabilitation Unit Care Pathway RMDC Rehab Unit ICT, GP, DN, Soc.Services, Acute Hospitals, Self/Family Referral Referrer Informed Referral Accepted for Rehab Referral not Appropriate Primary contact to the Patient Patient Registration Info re Appointment day/time Regular maintenance work/ periodic review Rehab commences Discharge as appropriate

5 3.3 Population covered a) The Provider will offer rehabilitation services to individuals living in the Romney Marsh Area, including Dymchurch, St Mary s Bay, St Marys in the Marsh, Ivychurch, Newchurch, Brenzett, Brookland, Old Romney, Lydd, Lydd on Sea, Greatstone, Littlestone and New Romney. b) Consideration to people registered to a GP within South Kent Coast Clinical Commissioning Group area but not usually resident on the Romney Marsh may be agreed on an individual basis by the Provider but rejections must be communicated to the Commissioner at contract performance review meetings. 3.3 (a) and (b) above are the service limitations under clause SC7; of the Service Conditions of this contract. 3.4 Any acceptance and exclusion criteria and thresholds Referral criteria & sources Individuals who would benefit from the input of a multi professional team to provide short term rehabilitation. Individuals who meet the Intermediate Care Team criteria although acceptance is the decision of the Provider. Referral route Referrals are accepted from:- GPs District Nurses or the Health Care Professionals Social Services Case Managers The Romney Marsh Day Centre s Management team. Self-referrals Exclusion criteria Individuals with complex needs unless agreed by the Romney Marsh Day Centre Management team. Clients who do not meet the Intermediate Care Team criteria. If the caseload is beyond manageable capacity. 3.5 Interdependence with other services/providers Intermediate Care Team of Kent Community Healthcare NHS Trust. GP referrers. Voluntary sector organisations and groups that have contact with the Provider. The Provider will co-operate with professional supervisors for the Provider s Rehabilitation Workers in order to preserve the Workers qualification status.

6 4. Applicable Service Standards 4.1 Applicable national standards (e.g. NICE) The complete sections SC1 and SC2 of the Service Conditions of this contract apply. 4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges) The complete sections SC1 and SC2 of the Service Conditions of this contract apply. 4.3 Applicable local standards To employ and pay 50 hours of Rehabilitation Workers per week the Provider to employ 2 suitably qualified individuals. To ensure that the Rehabilitation Workers are appropriately qualified and trained. To ensure that the Rehabilitation Workers are Disclosure and Barring Service checked. 5. Applicable quality requirements and CQUIN goals Applicable Quality Requirements (See Schedule 4) 6. Location of Provider Premises The Provider s Premises are located at: 7. Individual Service User Placement Not Used