Sutton and Merton Community Services Home based rehabilitation Community Rehabilitation Team Patient information
NHS Sutton and Merton Vision Our vision is to promote independence and provide excellent co-ordinated care delivered within the heart of the community. This will be achieved through leadership and clinical excellence from staff, and involvement, selfcare and personalisation from our patients.
Contents Contents Home Based Community Rehabilitation Service 1 Who can benefit? 1 What is rehabilitation? 1 Who are the team? 2 Physiotherapists Occupational therapists Assistant practitioners Rehabilitation assistants What to expect 2 What don t we do? 3 What do we expect of you? 3 How long will I receive community rehabilitation for, and what happens afterwards? 4 How much does it cost? 4 Who will provide my medical care? 4 Further information 5 Consent Accessibility How do I make a comment or complaint? How do I gain access to my medical records? Advocacy Service Contact us 6 The Community Rehabilitation Team NHS Direct
Home Based Community Rehabilitation service can provide: Home based rehabilitation Short term rehabilitation to support your recovery after discharge from hospital. Short term rehabilitation at home to prevent you being unnecessarily admitted to hospital. Personalised rehabilitation and enable you to live as independently as possible at home. A way to link you to other services which may help you to look after yourself and remain at home. Who can benefit? The service is open to anyone with a Sutton and Merton GP and over the age of 16. You could benefit from community rehabilitation if: Your mobility has temporarily deteriorated, so that you cannot care for yourself (e.g. after a fall, operation or whilst recovering from an infection). You are housebound and cannot attend a hospital or clinic for therapy. Your medical needs can be safely met by your GP in the community. You can participate in your rehabilitation and are motivated to regain your independence. What is rehabilitation? Rehabilitation is about using goals which you have identified to restore your independence with mobility and activities of daily living such as washing and dressing and preparing meals. 1
Who are the team? 2 Physiotherapists They may help you to improve your walking (indoors or outdoors), help you to improve your ability to use the stairs, create a personalised exercise programme to improve your physical strength or provide falls education and balance exercises. Occupational therapists They may help you restore your ability to perform your day-to-day tasks like getting washed and dressed or preparing your own meals. They may also provide you with adaptations at home to help you get on and off the bed, toilet or chair as part of your rehabilitation plan. Assistant practitioners Assistant Practitioners carry out some assessments on behalf of the therapists and can agree your rehabilitation goals with you. Rehabilitation assistants The rehabilitation assistants may be closely involved in your rehabilitation. Rehabilitation assistants help you to achieve your rehabilitation goals and guide and direct you in your personal rehabilitation plan. What to expect : A therapist will undertake a detailed assessment of your rehabilitation needs. A personal rehabilitation plan will be developed based on your needs, in agreement with you. Your rehabilitation plan may include working towards independence with personal care, meal preparation, mobility and exercises to help you gain independence.
Home based rehabilitation Rehabilitation visits will be carried out - often by the rehabilitation assistants who work towards the plan set by you and your therapists. The team may work with other services to ensure your needs are met and may refer you onto other appropriate services if necessary, with your consent. Please note that the number of visits you require is assessed by your therapist(s) and is very specific to each patient. What don t we do? We do not provide carers. We do not provide a cooking service, shopping, cleaning, laundry or financial support. We do not provide respite or convalescence. We do not assist patients with taking medications but if appropriate we can remind and prompt you to do so. What do we expect of you? Consent to participate in your rehabilitation programme. Support of your family where possible to promote your self-care. You are welcome to have a family member/friend present if required. Motivation and a willingness to engage in your rehabilitation plan as actively as you can. Access to your property if you cannot get to the door. Please be aware we may ask for two sets of keys to ensure our team can provide your rehabilitation visits. 3
How long will I receive community rehabilitation for, and what happens afterwards? You will receive rehabilitation until you have achieved your goals or have reached your optimum performance with our team. Our therapists, assistant practitioners and rehabilitation assistants regularly evaluate the progress you are making with your goals and if you require ongoing support we may refer you onto other appropriate services e.g. Social Services. How much does it cost? Your rehabilitation plan is provided by NHS Sutton & Merton and you will not be charged. However if it is identified that you require social services you will be financially assessed and may be charged by social services. Who will provide my medical care? Your GP will provide any medical care you need. To take part in rehabilitation you need to be well enough to follow the rehabilitation plan. If you become unwell your GP may need to be involved or you may need to be checked at the hospital. 4
Further information Consent Home based rehabilitation All assessment/treatment goals will be jointly agreed between yourself and the healthcare professionals involved in your care. These goals will be clearly recorded in your patient records. You have the right to change your mind regarding your treatment at any point during your rehabilitation with the Community Rehabilitation Team. If following assessment/ treatment you decide you do not wish to continue to receive rehabilitation, then a discharge letter will be sent to your GP and the referring healthcare professional will be informed if appropriate. How do I make a comment or complaint? If you wish to make a comment or suggestion about the Community Rehabilitation Team (CRT) service or if you are unhappy with any aspect of your care from the CRT, please contact the CRT Service manager on 020 3458 5555. If you are still unhappy then you may like to speak to a Patient Advice and Liaison Service (PALS) officer who will listen to your concerns and liaise on your behalf to try and resolve issues. PALS are part of The Royal Marsden NHS Foundation Trust. PALS can give you guidance on raising a concern or complaint. Please contact the PALS Help Centre on 0800 783 7176. You can also contact PALS via the online feedback form on The Royal Marsden NHS Foundation Trust website, www.royalmarsden.nhs.uk/contact/feedback 5
How do I gain access to my medical records? Should you wish to see your notes for any reason you are required to contact the Records Manager who will send you the necessary forms and guidance. Please note, there is a charge for this service. For further information contact Medical Records at The Royal Marsden, Chelsea on 020 7811 8300. Advocacy service If you require any advocate for medical decisions your GP can refer you to the advocacy referral co-ordinator 0845 017 5198. Contact us The Community Rehabilitation Team We are open between 8am 5pm, Monday to Friday. Home based rehabilitation queries please call 0203 458 5555. Outside these hours please call 0845 603 1087 or for medical concerns contact your GP or NHS direct. NHS Direct For information about health and medical concerns call 0845 4647 or visit the website at www.nhsdirect.nhs.uk 6
Home based rehabilitation Notes and questions 7
Copyright 2012 The Royal Marsden NHS Foundation Trust All rights reserved Printed xxxx 2012 Planned review xxxx 2014 Sutton and Merton Community Services 120 The Broadway London, SW19 1RH www.smcs.nhs.uk This leaflet is evidence based wherever the appropriate evidence is available, and represents an accumulation of expert opinion and professional interpretation. Details of the references used in writing this leaflet are available on request from: The Royal Marsden Help Centre Freephone: 0800 783 7176 Email: patientcentre@rmh.nhs.uk No conflicts of interest were declared in the production of this booklet. The information in this booklet is correct at the time of going to print. xx-xx-xx