Rehabilitation, Reablement and Recovery (3Rs)

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1 Rehabilitation, Reablement and Recovery (3Rs) Background and objective of project We have been working with patients, carers and our health and care partners to improve rehabilitation, reablement and recovery services (3Rs) for South Gloucestershire. The 3Rs are services that support people as they recover from illness or injury, or after surgery. They span both health and social care services and involve a variety of organisations including services provided in acute hospitals and in the community, including at home, and they are provided by a range of professionals and their support staff including hospital consultants, nurses, therapists, GPs and social workers. While the majority of people admitted to hospital recover from illness or injury with limited additional support, a significant minority particularly frail older people may need some form of active therapy over a longer period to ensure effective recovery and maintain their independence. An ageing population with increasingly complex needs is increasing demand for these services. This is a particular issue for South Gloucestershire where the number of people over the age of 85 is projected to increase 27% by 2018 and 153% by At the same time, funding for public services is likely to be constrained for the foreseeable future. This means that we cannot rely on significant additional resources to meet this rising demand. It also means we need to make sure that we use every penny as effectively as possible. PPI activity to date There has been a great deal of PPI activity around the 3Rs over the past few years, going back to A series of workshops and meetings were held during 2012 and early 2013 to understand what issues are important to patients and carers in the rehabilitation, enablement and reablement services, and the following key issues were identified: Timely service provision Services which are individually tailored Services which are provided locally Services which are based around regular reviews 1

2 Services which are integrated across organisations Services which keep the patient and carers informed Further details can be found in the PPI report from this engagement, What Matters to Patients, which can be found on our website. This period of engagement led to the development of a local model of care for South Gloucestershire which was agreed in August 2013 by the South Gloucestershire Rehabilitation, Reablement & Recovery Project Board. The CCG then established a Rehabilitation, Reablement and Recovery Programme Service User and Carer Reference Group. Invitations were sent out to relevant stakeholder networks inviting service users and carers, who were currently using or had used any rehabilitation, reablement and recovery services in the past year, to join the reference group. A series of meetings were scheduled between December 2014 and March The key themes emerging from the Service User and Carer Reference Group meetings were as follows: greater support and information is needed upon diagnosis; the importance of the role of the voluntary sector in delivering support and information; there were some positive experiences of hospital care; several people encountered difficulties upon discharge in understanding what support was available to them and accessing support, and suggested that a key contact would have been helpful; a feeling of being alone to make sense of what care is available; follow up about eligibility for services, following assessment, was sometime limited; better integration between social care and health services; a perception that support available for self-funders was not so readily available; a perception that support was not available for families once they had agreed to care for a relative. Having heard the views of service users and carers, the proposed service model was shared with the Service User and Carer Reference Group who were given the opportunity to discuss the model, ask questions, and give feedback on it. Evidence gathered during these sessions demonstrated that the group believed they had been heard by the CCG, that they understood the proposed service model, and that they were in agreement with it. Members of this group have been well-engaged throughout. Further details of engagement work undertaken up until March 2015 can be found in the report taken to Governing Body in that month, which can be accessed here: mplementing_the_3rs_model_of_care_for_south_gloucestershire.pdf 2

3 During the procurement phase there was further patient and public involvement in two key areas. Firstly, a service user and a carer representative were part of the Procurement Evaluation Panel which reviewed the Outline Delivery Model and the Detailed Delivery Model and made recommendations to the 3Rs Procurement Programme Board. Secondly, a patient and public involvement workshop was held in October 2015 which gave patients and the public the opportunity to reflect on whether they felt sufficiently assured that the feedback which had been gathered during the preprocurement phase of the project had been considered and reflected in service specifications and the delivery model. The outcomes of that work were shared with future providers, South Gloucestershire HOSC committee and those who attended the workshop. Overall the group concluded that whilst the model looked good they had not yet seen sufficient evidence to feel fully assured that patient and public involvement messages had been reflected in service specifications and the model. They highlighted some key areas and these are set out within the table below, which also records the action which has been taken as a result of this patient and public feedback. You Said People are experiencing delays between referral and treatment We Did Phase 1 of the 3Rs programme has focused on the development of health and social care capacity in the community and the implementation of new delivery models on a test and learn basis. In particular, this has included: Commissioningnew rehabilitation beds in care homes, with dedicated therapy support from our community services provider Commissioning new capacity in the community to support timely discharge from hospital the day they are medically fit Establishing, with South Gloucestershire Council, a new reablement service which provides additionalsupport 3 Through this we are, and will continue to, help to reduce unnecessary

4 admissions to hospital and by further reducing reliance on acute hospital inpatient services eliminate delays in accessing services for those who need to be admitted. Concerns were raised around the impact of delays which people perceived were sometimes due to increased demand, with people wanting assurance that this could be overcome. Delays occurring in discharge because of, for example, delays in paperwork to enable someone to move on to a nursing home. As noted above the key purpose for the 3Rs programme is is to simplify and streamline the pathway, to reduce avoidable delays, to minimise the time spent in hospital and to provide as much care as possible close to or in the person s home. In addition to the above work undertaken to commission additional capacity, significant work has been done to ensure that the needs of individuals are identified early on during an admission and that acute and community services work together to place patients in the right services at the right time. This has included the roll out of Discharge to Assess pathways, the roll out and consistent application of agreed rehab levels of need, and ensuring that staff in acute services are aware of available services and capacity on any given day. Implementing an Integrated Discharge Service at NBT run by staff from Sirona, Bristol Community Health and NBT to help get people out of hospital Delays in the provision of therapy There has been an increase in investment in therapists at Sirona to reduce delays There is not enough in the model at the moment about how people will be engaged and how the services will be shaped to them. Service users and cares will be involved in the development of individualised care plans to ensure services are shaped around them Person-centred is the key. 4 This is central to the high level model of care and the model for South Gloucestershire, it is the foundation of all the Sirona and NBT plans

5 3Rs services are for all South Gloucestershire adults not just the elderly. Difference between being ready for discharge from a clinical viewpoint, and other factors which may impact upon people s readiness. Carers may have additional vital information about whether discharge is appropriate. More detail needed about support for selffunders within this model e.g: Handover long term care packages relationship with LA funding We need information for carers about options and funding Will services allow for people to choose if they would prefer a male or female professional? What do we mean by closer to home? It can mean different things to different people. Continuity and quality of care are vital. How long does therapy go on, and how is the quality of care carried over when e.g. therapy ends and domiciliary care takes over? Ensuring there is consistent and good quality post-discharge follow up Supporting services in rural areas Agree, although older people are the largest user of these services Carers will also have an assessment to make sure they are also ready for discharge This will be part of carers assessment Yes, this is part of Sirona s practice It means to a community bed and then home or to direct to home with appropriate support or to a long term care facility We agree, which is why we are working on a rehabilitation prescription which will follow the service users This will be described in the individual care plan or rehab prescription which will stay with the service user as they move along the pathway and be updated As Sirona are part of the Integrated Discharge Service they will ensure their colleagues in the community follow people up post discharge The model has in-reach therapy into 5

6 people s homes and into community beds in a number of locations Needs change over time. We would like more clarity over how the reviews are going to happen / frequency. There should be flexibility around the timing of reviews. Frequency of reassessment needs to be appropriate to the individual s needs. Who is monitoring rehabilitation in nursing home beds how is their progress monitored? Healthwatch discharge report showed very low percentages of people have voluntary / community sector support. This will be part of a person s individual care plan or rehab prescription which will stay with the service user as they move along the pathway and be reviewed at key points As above The Sirona management team monitor the usage and outcomes of the community rehab beds regularly as part of their ongoing service monitoring. This is reported to commissioners on a quarterly basis, including bed occupancy and usage and the outcomes achieved by those using the beds. This is currently measured using the Elderly Mobility Score. The community rehab beds also form part of the regular monitoring information supplied to commissioners as part of the overall Sirona contract management process. In addition, an audit of the community rehab beds is currently being undertaken. This consists of both a high level audit of length of stay rates and whether these have reduced, along with a more detailed patient level audit looking at outcomes. This is being addressed by the new model of community service provision centred around six local clusters of GP practices to support more people to remain independent and living in their own homes and to build community capacity by involving the voluntary sector. Handover of care between those in As Sirona are part of the Integrated 6

7 hospital and wherever they are going next is important Integration across borders is particularly challenging. Need to move people out of silos. Recognition of the challenges around this. Better integration between health and social care we want assurance that e.g. community nurse / therapist coming into a home works with other support e.g. from Brunelcare Discharge Service they will ensure their colleagues in the community follow people up post discharge so there is a good handover between NBT and Sirona staff. The Integrated Discharge Service aims to do exactly this Sirona are implementing a new joint approach with Brunelcare who provide the LA s reablement service, focusing on supporting individuals to remain as independent as possible,avoiding hospital admissions and expediting timely hospital discharges Information and clarity are vital. Agree, which is why Sirona are implementing individual care plan/rehab prescriptions Need for a leaflet which would clearly set out what services people can expect The individual care plan/rehab Service users and carers must be kept informed and helped to navigate a complex system. Importance of communicating with carers The individual care plan/rehab Carers assessment should help with this 7

8 Care planning must include carers (recognising data protection issues). Carers have an important advocacy role. How can people make sense of the service? There is talk about levels and tiers, but people need to understand the criteria by which discharge plans are being made. The individual care plan/rehab The individual care plan/rehab Who is providing what? Need for clarity. The individual care plan/rehab More detail is needed around care for The carers assessment will do this carers more support and information about this. Whether or not funded, we need to have equal access to carers support How do people know where to go and what to ask More IT to give information e.g. on where people are within the system Need for a single point of access so people are clear on how to get in to the system or get advice. Should be telephone based. Care Navigator role is very important (not only in crisis) but this is not clear within the current model. Model needs to capture more than the largest group, i.e. the elderly. It can feel as though services are being overlyfocused on that group, rather than a focus on keeping people healthy at home. Model needs to demonstrate that 3Rs services are for all South Gloucestershire residents (adults) not just the elderly. The carers assessment will do this The individual care plan/rehab The individual care plan/rehab Sirona care & Health operates a 7 day single point of access (Joint Community Access Portal JCAP) which is collocated with the LA s social care access point The Care navigator will do this It is for all people who need rehabilitation, irrespective of age, although the majority of users are older people. There are links with the major trauma centre at NBT as these tend to be younger people needing rehabilitation 8

9 The model currently feels as though it is focused more around those going into hospital and not enough on putting services in in a timely way which would prevent people from reaching crisis point. The model does not include people who may never be able to return home, and need to go into a permanent bed in a care home. Perhaps there should be multiple models to reflect a range of scenarios Sirona are implementing the following to avoid admissions:- Expanding the role and skills of the Emergency Care Practitioners to provide rapid response/admission avoidance and to increase the capacity and capability to respond consistently and reliably 7/7 Providing joint in-reach rehabilitation to four Residential Homes in South Gloucestershire to identify existing residents who will benefit from short term therapeutic rehabilitation to avoid hospital admission.if the pilot is evaluated positively the model will be rolled out to other homes in Community IV Therapy service for range of conditions that can be treated safely at home including treatment programmes for up to 6 weeks IV therapy Working with the LA to develop a community connectors service that will harness a range of community resources including voluntary sector services to maintain older people within their communities from April A bid to provide a falls prevention service from April 2016 within S Gloucestershire is still being finalised Yes it does, this is pathway 3 There is, there are three pathways:- Pathway 1 is to the persons home Pathway 2 is to a community bed Pathway 3 is to a long term care home bed We need clarity about people who move in See above 9

10 and out of the box in the current model e.g.: Long term care outside 3Rs Maintenance rehab (or do they have to wait to get back in links to timeliness When does rehab journey end? How do we know? Who decides? Who is deciding on proxy measures, what are the KPIs? What are the arrangements for clinical guidance and monitoring? Case studies for evaluation should include patients who are atypical as well as typical The journey s end will be different for different people but often will end with support from the reablement service provided by Brunel care We have a draft set of KPIs which we plan to consult on with service users and carers As above As above What is the governance? clinical model? Consultant led? GP led? Ward-manager? What is the role of the GP? What is the All these clinicians are involved in the pathway from the Integrated Discharge service to the cluster model As part of the cluster model to avoid admission and support post an admission Therapists currently they have different specialities, is this the best use of resources? Or should there be a multidisciplinary therapist? Training where and how can this be done in rehabilitation? We are concerned that the establishment (ideal) numbers will be hard to recruit in Good point, there is work being done nationally re generic support workers It can be done in rehabilitation as part of in-reach support to people s homes and into Nursing homes Sirona have been able to recruit staff as part of phase 1 and these staff will 10

11 reality. We feel this might particularly be a problem in recruiting qualified staff compared to homecare etc. Tell us what has been changed as a result of what we have told you, and what has been rejected, and why. We want more conversations with Sirona and NBT, and would like this to include people on the ground as well as managers. move over to support phase 2 This report sets this out, and there will be ongoing patient and public involvement as the 3Rs project continues. Noted, we will include this iin a future event. As highlighted in the above table, one of the key things people asked for during the session in October 2015 was further engagement in the development of key performance indicators and the monitoring and evaluation framework for the service. As a result of this request, on 22 nd February 2016 a workshop was held with service users, carers and members of the public to help refine our monitoring and evaluation framework, and ensure that patient experience will continue to be captured once the service is in place. We shared with attendees, in advance, a document which set out the kind of things we thought we should measure and monitor and how we should do that. The session focused on getting people s views on this, to make sure we had thought of all the important elements of monitoring how we are doing, so we can continue to build and improve the services we provide. Those who attended provided us with detailed feedback which can be found on our website. These comments have been taken on board and a revised version of the monitoring and evaluation framework is now in use. Next Steps Work continues on the 3Rs with Phase 2 continuing to focus on the development of new community health and care facilities at the old Frenchay Hospital and Thornbury Health Centre sites. This is a key part of the 3Rs programme and we are working closely with our partners including the local authority and NHS England to progress our plans. The work is being taken forward by Sirona and NBT as our main service providers and a provisional site plan and timetable were presented by Sirona in April. This plan 11

12 anticipates 80 beds on each site made up of 44 NHS beds plus 36 care beds, with additional extra care housing and outpatient accommodation at Thornbury. Further information, including the most recent 3Rs newsletter can be found on our Get Involved web pages here: We will continue to work with Sirona and NBT who are committed to ongoing patient and public involvement as this work continues. 12