CCC - Improving Adult Rehabilitation Services Phase 2

Transcription

1 Work within a health team, in the midst of integrating rehabilitation with adult nursing community service, to establish effective routes of training and support to band 3 workers (traditionally health care assistants) to increase opportunities for patients to be rehabilitated. Now been asked to roll this out to social services. How can this be done? To achieve meaningful dialogue with commissioners about service provision and increase their knowledge to ensure best service to meet individual patient needs. To improve the journey for patients in transition from hospital to home, who require a temporary stay in a care home, by integrating the health and social care team who support them in this environment, redefining the principles and practice of this integrated workforce. I am training volunteers to deliver rehabilitation and re-enablement programmes, eg communication partners, community buddies. I would like to evidence the added value AHPs can bring to long term condition management in respect of self management, social integration and good health and wellbeing. Pathway for Neuro patients how? outcomes? data? Eliminate waiting list for rehabilitation in the community a seamless transition from acute to community services Suzanne Avington, Team Leader for Community Rehabilitation in Rushcliffe, County Health Partnerships, Nottinghamshire Healthcare Ros Simpson, Business Development Manager, Woodlands Neurological Rehabilitation Service, Christchurch Group Ltd Nichola Durrant Community Intermediate Care Manager, NHS Liverpool Community Health Lynn Keirs Strategic Therapy Lead Adults & South Locality manager, The Rotherham Foundation Cat Williams Stroke Specialist Physiotherapist, Leeds Teaching Hospitals Rushdy Beden GP, Rehabilitation Medicine Specialist, Leeds Improving Adult Rehab - burning issues at event v2 1

2 Map out current pathway for patients with LTNC and stroke experience. Learn about pathways developed, re neuro Social Services, NHS, independent sector, third sector working together, around the client? I would like to engage with commissioners to look at improving clarity of commissioning neuro-rehab and where lines are drawn in terms of: timescales; domains/goals for rehab; outcomes achieved; budget; CHC criteria. Most importantly, if patients can see clear commissioning definitions, pathways will be facilitated more easily. Training rehab workers of the future Implementing TOMs outcome measures if possible using System One can you help? To redesign the role of HCA/RA staff into one new innovative role to promote integration of nursing and therapy teams Kirsty Forrester Clinical Manager Leeds Community Stroke Team / Occupational Therapist Margaret White Adult Neuro Rehab, Neural Pathways (UK) Ltd Vicki Gilman, Neural Pathways (UK) Ltd Angela Murphy Senior Lecturer in Occupational Therapy and Occupational Science, Practice Placement Coordinator, Leeds Metropolitan University Lynne Peters Neurosciences Coordinator, Bridgewater Community Healthcare NHS Ashton Leigh and Wigan Division Helen Love Locality Lead (South) & Lead Therapist Integrated Primary Care Service, CNWL, Camden Provider Services Improving Adult Rehab - burning issues at event v2 2

3 Lean systems and processes to facilitate seamless, timely discharges from hospital by a multi-disciplinary, multi-agency team, to enable discharge to the most appropriate setting with the most appropriate community multi-agency team. Developing a pre-registration curriculum that ensures the future workforce is fit for purpose and I able to deliver the best service to patients in the most appropriate setting to learn the process of transfer of care from identification of need to delivery of the rehabilitation pathway Rehab and major trauma? Let s talk/share!!! Delivery of active rehabilitation for neurological conditions in a community setting Ensuring physio/occupational therapy, etc, specialist assessments and ongoing discipline specific notes remain within new electronic MDT records (eg for ICT) anyone using MDT electronic records? *MDT multi disciplinary team * ICT Intermediate Care Team John Schooling Strategic Pathway Partnership Lead, Rehabilitation Pathway, Tameside and Glossop Community Healthcare, Stockport NHS Foundation Jill Kent BSc (Hons) Physiotherapy Programme Leader, School of Health & Social Care, Teesside University Deborah Clough Operational Lead for the Community Assessment and Rapid access service (CARA). Lead for Community Physiotherapy and the Falls service, Thameside and Glossop Lorna Williams Clinical Physiotherapy Manager MSK, Leeds Teaching Hospital Harvey Sihota Director, Standing Start Jo Hopes Professional Lead (Physiotherapy) Out of Hospital Care, Burmantofts Health Centre, Leeds Improving Adult Rehab - burning issues at event v2 3

4 Improve rehabilitation services working together, ie intermediate care/ reablement/prevention services, to create a more joined up, flexible and accessible rehabilitation pathway for people living in Cumbria. Please me. I can signpost to NICE guides for commissioners and relevant commissioning drivers that might help in developing rehab services Review educational opportunities for rehabilitation to offer a dedicated multiprofessional course that will bring together relevant professional skills to teach patients / service users Universities need to know what skills the rehabilitation community need for the future. Tell us and the education commissioners. Do we need to educate support workers? Do we need a rehabilitation professional? Should workforce be skilled-based not profession-based? Pharmacist support with medication adherence referral pathways for patients, health and social professions Measuring wider social/participation outcomes and improvements (value added)? for clients using high-tech alternative and augmentative communication (AAC). Measuring impact of AAC as part of pathway Development of a support worker qualification for AHPs Anne Phillips Development Manager, Adult Social Care Commissioning, Adult and Local Services, Cumbria County Council Naomi McVey Commissioning Adviser, National Institute for Health and Clinical Excellence Pauline Buttling Department of Allied Health Professions, Faculty of Health and Wellbeing, Sheffield Hallam University Jackie Hammerton Professional Lead Physiotherapy, Sheffield Hallam University Nina Barnet, Consultant Pharmacist, Older People, North West London Hospitals Josh Mars Specialist Speech and Language Therapist, Children & Family Services, NHS Leeds Community Healthcare Kate Grafton Principal Lecturer/Teacher Fellow, Course Leader BSc (Hons) Physiotherapy, School of Rehabilitation and Health Sciences Improving Adult Rehab - burning issues at event v2 4

5 To create/protect time for rehabilitation in a busy acute setting How can I ensure future commissioning of a specialist head and neck team geographically? Taking on different specialisms? Or offering more services that we can provide? eg. dry mouth, modified consistency, etc To establish patient led rehabilitation plans which all MDT work with 24/7 to achieve a safe planned estimated discharge date (EDD) Art therapy (with appropriate psychological help) for people with long term conditions helping people adjust when they need the help! Don t wait for it to happen ask forgiveness, not permission. We have a 3/52 window to influence. Deliver the nutritional element of a cardiac rehab programme without direct input of a dietician Promote early supported discharge from elderly rehab wards to community rehab team: improving working practices; improving communication; reducing paperwork; breaking down barriers; providing a more seamless pathway for patients. We are reconfiguring our intermediate care service to a step down bed and community, seamless service. Difficulty: joining up, integration, seamless. the service? Odeth Richardson Head of Occupational Therapy, Newcastle Upon Tyne Hospitals NHS Foundation Jo Jefford Head and Neck Community Rehabilitation Team in South East London Karen Durrant, Rehabilitation Clinical Manager, Doncaster and Bassetlaw FT Sally Weston Art Psychotherapist Osborn 4 Neurological Rehabilitation Unit, Northern General Hospital, Sheffield Jackie Turnpenney Lead for Rehabilitation and Survivorship, National Cancer Action Team Zoe Cook Professional Head of Nutrition and Dietetics, Royal Oldham Hospital Alex Crawford Team Leader/Senior Physiotherapist, Community Rehab team, Walton Hospital Peter Woods Project Manager - Intermediate Care Bassetts House Broadwater Gardens Farnborough Kent Improving Adult Rehab - burning issues at event v2 5

6 Rehab from day one of illness? patient questionnaire (daily/weekly): identify patient blocks; synchronise goals; sign post services; reduce admissions; improve patient outcomes Leeds AHPs share your contact details, get in touch, improve communication. better together, it s good to talk Active case management. Integration of existing services. Single point of access through computerised matrix Streamline access to community services such as single point of access or active case managers Intend to develop a framework for rehabilitation to cover all aspects of: commissioning; service delivery; social care support; long term support; return to work. Empowering patients to help themselves joint goal setting We have created an online cardiac rehab programme Using Jonah to improve communication within Intermediate Care Team and effect timely discharges from Intensive Care beds to enable patient to continue their rehab in their own homes. Raising awareness of community pharmacy into the rehab pathway. We are an untapped resource. John Whitehead, CCG Commissioner, Torbay and South Devon NHS Janice Martin Head of Physiotherapy for Leeds Teaching Hospital Heather Duff Stroke Therapy Manager, Southport and Ormskirk Acute Hospital Julie Edwards, Community Rehab Occupational Therapist, Southport Julie Rigby Network Director, Greater Manchester Neurosciences Network Julie Emerson Specialist AHP, Brain and CNS Tumour Rehabilitation and AHP Lead for Greater Manchester and Cheshire Cancer Network Christopher Brough, Leicester NHS Liz Salt Senior Therapy Practitioner-Occupational Therapy, Community Rehab team, Walton Hospital Kat Ions Operations Manager North, MedicX Pharmacy Improving Adult Rehab - burning issues at event v2 6

7 Promote rehab across the new clinical commissioning groups (Sheffield and Bassetlaw, Hull, North Lincs, NE Lincs, North Yorkshire) Help young people climb the ladder to adulthood self management pathways Get more feedback from clients about the service we provide Developing pathways and strategies to support rehabilitation clients with unaddressed pain needs Improving patient access and outcomes for patients with long term conditions Specialist rehab service integration acute to community Sherry McKiniry NEYHCA Professional Lead, Survivorship, Rehabilitation & End of Life Care John MacFarlane Consultant in Rehabilitation Medicine, Specialist Care Group Northumberland, Tyne and Wear NHS Judith Mitchell Locala Community Partnerships CIC, Community Rehabilitation Team Rachel Winter Therapy Team Lead, Kentish Town Health Centre, Integrated Primary Care Service, CNWL, Camden Provider Services Simon Dickinson Head of service for Orthotics at Nottingham University Hospitals and Chair of the NHS Orthotic Managers Group Abayomi Salawu Consultant in Rehabilitation Medicine and Senior Clinical Tutor Hull/York Medical School; Clinical Lead, Rehabilitation Medicine Service; Northern Lincolnshire and Goole Hospitals NHS Foundation Improving Adult Rehab - burning issues at event v2 7

8 Identifying most appropriate rehab outcome measures How to deliver cost-effective 7 day services, i.e. to overcome discharge in community equipment and service provision Smooth major trauma and specialist rehab pathway design Improving care pathway integration in a multi-site clinical setting when we still use paper files! Integrating and developing rehab and ensuring a seamless service within ambulatory care (to include prevention admission/ quality-of-life interventions) Angela Green Lead clinical research therapist, Hull and East Yorkshire, Hospitals NHS Angela Green Lead clinical research therapist, Hull and East Yorkshire, Hospitals NHS Angela Green Lead clinical research therapist, Hull and East Yorkshire, Hospitals NHS Paula Griffiths, BWS Clinical Coordinator, Otto Bock Healthcare PLC, West Midlands Sinead Stanley Ambulatory Care Project Manager NHS Airedale, Bradford and Leeds Improving Adult Rehab - burning issues at event v2 8