Shetland NHS Board. Board Paper 2017/28

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1 Board Paper 2017/28 Shetland NHS Board Meeting: Paper Title: Shetland NHS Board Capacity and resilience planning - managing safe and effective care across hospital and community services Date: 11 th June 2017 Author: Kathleen Carolan Job Title: Director of Nursing & Acute Services Executive Lead: Kathleen Carolan Job Title: Director of Nursing & Acute Services Decision / Action required by meeting: The Board is asked to note that between March and May 2017: The implementation of the interim measures to move staff to cover nursing vacancies, has maintained safe staffing levels across the hospital and community setting; We have successfully provided non acute rehabilitation and reablement in the community as an alternative to the hospital based model; We have maintained and in some cases improved our performance, in comparison with the same period in 2016; We have demonstrated that we can effectively manage specialist, inpatient care and match capacity with demand via a hospital bed base of 44 Acute beds; We have reduced the overall cost of nursing staffing, particularly reliance on supplementary staffing between March and May 2017; The Board is therefore asked to: Support the decision to permanently close the stand alone Rehabilitation Unit at the Gilbert Bain Hospital. This will allow us to formalise the arrangements for new posts for the staff directly affected and fully implement the community based rehabilitation model. High Level Summary: Older people are major users of health and social care services and there are nationally predicted rises in the likely demand for mental health, long term conditions and acute health care as well as community based services. Given this context of demographic change and the increasingly complex heath and care needs identified, we will need to continue to look at how we can shape local services in order to meet these service demand predictions. Our strategic plans must also include ways of supporting people with more complex needs in the community setting in a safe and sustainable way and we have recently refreshed our joint commissioning plans to reflect our demographic, epidemiological and service design challenges 1. The Integration Joint Board (IJB) approved the strategic plan in March 2017 and NHS Shetland Board approved the plan in April Shetland Islands Health and Social Care Partnership: Joint Strategic Commissioning Plan ( )

2 In line with the strategic plan, the IJB also approved a proposal in March 2017 to extend the intermediate care team (ICT) 2 so that further resources would be aligned to the team in the community to provide more complex care at home, including non acute rehabilitation. At this meeting they also directed NHS Shetland to continue to deliver acute rehabilitation in the hospital and to support the shift in the balance of care through a disinvestment in Inpatient hospital services in line with the proposed delegated budgets. Since March 2017, the ICT has been actively recruiting to fill the vacant posts created as a result of increased investment. In February 2017, an operational decision was taken to close the Rehabilitation Unit on an interim basis as part of the Winter Plan escalation procedures. The reason for this decision was the need to support safe staffing levels in other services across the hospital and community. It also provided an opportunity to test the community rehabilitation model and release nursing staff from the Rehabilitation Unit (from March 2017 onwards) to support community based services including the ICT. This report sets out the impact of the interim arrangements on: Patients who required reablement or rehabilitation as part of their recovery; Patient flow through the hospital and care home settings; Performance against a range of access and quality measures; Staff supporting the new rehabilitation pathway Key Issues for attention of meeting: We have carefully considered the impact on individuals who need a programme of rehabilitation and recovery following an acute illness. We have developed a community based model that removes some of the barriers that providing care in a hospital setting present (e.g. flexibility of staffing across hospital and community settings). Our key findings in testing the community based model and implementing interim arrangements were that: Safe staffing levels were maintained across the hospital, in order to deliver the necessary balance of emergency and planned care services; Services were resilient throughout the winter period and since interim arrangements were put in place to provide community based rehabilitation. This is shown in a range of performance measures including access to emergency care through the 4 hour A&E target, cancellation of theatre procedures, length of stay in hospital, patients delayed in hospital and bed utilisation; The ICT has demonstrated that with additional resources committed by the IJB, it has been able to provide early supported discharge and an ongoing programme of recovery where people have been identified as meeting the criteria for ongoing 2 Extending Intermediate Care in the Community (2017) 3 The Winter Plan: Capacity Management Plans for the Provision of Services Over the Winter Period

3 reablement or rehabilitation; Patients and staff have reported that the development of the community based rehabilitation model has not had a negative impact on patient care and support in the community has been organised quickly and proficiently. Patient feedback on their experience of receiving input from the ICT has been positive; Staff who have been working in interim placements have made really valuable contributions to the teams that they have been supporting in both the community and the hospital setting. For example, this has enabled services such as Day Surgical Unit and the Out Patients Department to manage increased numbers of ambulatory care patients and assist in the repatriation of services from NHS Grampian. Similarly, staff with experience of older people s medicine have supported community nursing teams and the ICT to increase its capacity. If the interim arrangements are made permanent, then the full year effect of the savings will be approximately 475,000 (recurrently) where the saving is attributed to the reduction in the running costs of the Rehabilitation Unit. The equivalency funding released from the closure of these beds has already been invested in community health and care services locally, and is in line with the policy of shifting resources from acute to community settings. In line with our organisational change policy, staff who are contracted to work on the Rehabilitation Unit will have the opportunity to join the extended ICT (where vacancies exist) or take roles elsewhere in the hospital or community we have a policy of no voluntary redundancy across the NHS. Impact of item / issues on: Patient Safety: Staffing/Workforce: Finance/Resource: Assets and Property: Equality & Diversity: The community rehabilitation model which has been tested between March and May 2017 is in line with evidence base for models of intermediate care. The use of the Winter Plan procedures to use staff time flexibly to cover nursing vacancies has meant that we have been able to sustain all hospital based services and remain resilient when we have had increased demand for services. The NHS has a range of policies that will apply to any staff affected by an organisational change. There is also regular consultation with Trade Unions through the consultative mechanisms in place in both organisations and through the Joint Staff Forum. The interim arrangements have demonstrated that we can shift the balance of care and align resources in the community to enable more complex care to be safely delivered in this setting. An options appraisal will be undertaken to ensure that the space released in the hospital is fully utilised to support the development of services that are best placed to be positioned in the hospital campus. An Equality Impact Assessment was completed as part of the work undertaken to enhance the community rehabilitation model and extend the remit of the ICT.

4 Shetlands Joint Strategic (Commissioning) Plan supports and promotes equalities, health and human rights. Legal Issues: Under the terms of the Public Bodies (Joint Working) (Scotland) Act 2014, the IJB is responsible for the strategic planning of the functions delegated to it by the Shetland Islands Council and NHS Shetland and for the preparation of the Strategic Plan. The Strategic Plan (in which this proposal is positioned) specifies the services to be delivered by the parties; in this case NHS Shetland is responsible for inpatient services. Previously considered by: Committee/Group: The report has been considered by the Community Rehabilitation Project Board in May 2017

5 Shetland Islands Council Capacity and resilience planning managing safe and effective care across hospital and community services Date: June 11 th 2017 Version number: 6 Author: Kathleen Carolan, Director of Nursing & Acute Services Page 1 of 19

6 Table of Contents Chapter Item Page Number 1 Introduction Capacity and resilience planning managing safe and effective care across hospital and community services Monitoring the impact of using nursing staff flexibly to ensure safe staffing levels Test of change developing community based rehabilitation and impact on patient pathways Test of change developing community based rehabilitation and impact on hospital and community resources Wider impact of changes to older peoples care and success of joint working Findings developing community based rehabilitation and impact on hospital and community resources Conclusion 9 Appendix A Definition and origins of the ICT and Rehabilitation Unit 10 Appendix B Appendix C Key statistics to illustrate current service performance between March and May 2017 Intermediate care team performance between March and May Appendix D Rehabilitation and ICT pathway 19 Page 2 of 19

7 1. Introduction Older people are major users of health and social care services and there are nationally predicted rises in the likely demand for mental health, long term conditions and acute health care as well as community based services 1. In regard to the demographic changes predicted for Shetland, the number of people over the age of 75 years will increase from 1,657 in 2010, to 3807 by Given this context of demographic change and the increasingly complex heath and care needs identified, we will need to continue to look at how we can shape local services in order to meet these service demand predictions. Our strategic plans must also include ways of supporting people with more complex needs in the community setting in a safe and sustainable way. This will include services to support recovery and rehabilitation in the community (e.g. leading to better health outcomes and shorter lengths of admission following illness or surgery) and effective preventative services (e.g. helping people to restore their ability to perform their usual activities in life). We have recently reviewed and refreshed the strategic commissioning plan for health and social care services in Shetland 2. The plan reflects the demographic, epidemiological and design challenges we face; along with the outline service delivery plans we need to put in place to ensure that services are sustainable, person centred, safe and effective. The commissioning plan sets out the joint, strategic principles on which our service delivery plans are based to ensure that: Emergency care is maintained in Shetland, including medicine, surgery and maternity services; Care is only provided in a hospital setting if it cannot be provided safely and effectively in the community; Patients are only sent out with Shetland for healthcare if it cannot be provided safely and effectively locally; Attendance at hospital for diagnostic tests and investigations, outpatient consultations and minor procedures is kept to a minimum; Healthcare is provided by multi-professional teams, with reliance on single handed practitioners kept to a minimum; Increased use of technology is helping us provide care for the most vulnerable and elderly in our community; Older people and people who are living with long-term conditions will be getting the services they need to help them live as independently as possible; 1 A National Clinical Strategy for Scotland (2016) 2 Shetland Islands Health and Social Care Partnership: Joint Strategic Commissioning Plan ( ) Page 3 of 19

8 People will be supported to look after and improve their own health and well-being, helping them to live in good health for longer The commissioning plan describes the development of community based models of care to support self management, reablement and more complex rehabilitation and recovery provided at home. The Integration Joint Board (IJB) approved the strategic plan in March 2017 and NHS Shetland Board approved the plan in April In line with the strategic plan, the IJB also approved a proposal in March 2017 to extend the intermediate care team (ICT) so that further resources would be aligned to the team in the community to provide more complex care at home, including rehabilitation. This would lead to a reduced reliance on the need for hospital based recovery models 3. The definition and history of the development of the ICT and the Rehabilitation Unit can be found in Appendix A. 2. Capacity and resilience planning managing safe and effective care across hospital and community services In February 2017, an operational decision was made to close the Rehabilitation Unit on an interim basis as part of the Winter Plan escalation procedures. The reason for this decision was the need to support safe staffing levels in other services across the hospital and community. At the beginning of 2017, 8.5% of the hospital nursing posts were vacant (equivalent to WTE 7.31), which is consistent with similar challenges in the other remote and rural Health Boards across Scotland. In order to address this issue we have developed pathways for nurses to return to nursing in conjunction with Robert Gordon University and support students to train whilst remaining in Shetland through the Open University pre-registration programme for Adult and Mental Health nurses. However, despite widening access to nursing and promoting nursing posts through careers fairs and active marketing; we continued to carry a number of nursing vacancies in key service areas such as Day Surgery, Theatres, Outpatients, Renal, and Community Nursing as well as the Acute Wards. 3 Extending Intermediate Care in the Community (2017) 4 The Winter Plan: Capacity Management Plans for the Provision of Services Over the Winter Period Page 4 of 19

9 Therefore, in order to ensure that we continue to maintain safe staffing levels, we relocated nursing staff aligned to the Rehabilitation Unit to other departments at the beginning of March This includes community services and the ICT to assist with the growth and development of the team. 3. Monitoring the impact of using nursing staff flexibly to ensure safe staffing levels We have closely monitored the impact of closing the Rehabilitation Unit on an interim basis. This has included: Tracking patients through their recovery and rehabilitation pathway in hospital; The impact on patient flow and bed utilisation in the Hospital and Care Home settings; Holding regular meetings with staff to discuss the support needed and suitability of interim clinical placements; Evaluating the reduction in supplementary staffing needed to support safe patient care 4. Test of change developing community based rehabilitation and impact on patient pathways Since March 2017, patients who are medically stable but require ongoing rehabilitation have been receiving support through community based teams either at home or in a care facility. The pathway for non acute rehabilitation is shown in Appendix D. In the last three months, ten patients have been identified by the multi-disciplinary team as meeting the criteria for non acute rehabilitation. The average stay in hospital was 34 days. The post discharge recovery plans provided (or intended) are shown below. Seven people have been discharged home or transferred to another hospital. Two people remain in hospital but have plans in place. Discharge Setting Number Transferred to another hospital 1 Supported by family at home 1 Supported via Care at Home teams 1 Supported by Montfield Support Services 2 Supported by the ICT 5 The ICT has benefited from the interim move in staff through the release of the SCN from the Rehabilitation Unit, as well as other nursing staff who have been supporting patients in the community setting. Page 5 of 19

10 The ICT has facilitated a number of the community based reablement and recovery plans, as well as organising input from other locality based teams. Appendix C sets out the demand for ICT input between March and May During the three months where we have tested the impact of not having a dedicated Rehabilitation Unit in the hospital, we have not had any negative patient, family or staff feedback. Once patients have reached a stage where they are medically stable, plans have been quickly put in place in order to enable ongoing support and recovery to take place in the community. Nursing staff on Ward 3 have not raised any concerns about safe staffing levels or their ability to manage the increased patient dependency that is associated with providing support to patients who have non acute nursing needs. The issue most commonly noted as a result of this change is the time taken to organise complex discharge planning arrangements and we are actively reviewing how we can provide the necessary discharge liaison support to both acute wards as part of the evaluation of the revision of the pathway. Nurses and Healthcare Support Workers from the Rehabilitation Unit have been allocated to support patient care on Ward 3, as well as additional staff as needed in line with the overall acuity and dependency of the patients on the ward at any given time. 5. Test of change developing community based rehabilitation and impact on hospital and community resources In this reference period, we have seen a positive impact on Care Home capacity. Between March and May 2017, the median number of vacant permanent beds ran at 10 beds unoccupied each day, which is a significant shift from last year when beds were under more pressure. We have also seen a positive trend in hospital bed occupancy in 2016 the average bed occupancy for the hospital as a whole was 64%, whilst at the same time the hospital teams managed more people with increasing frailty and complexity. A comparison of bed occupancy in the hospital between March-May 2016 and March-May 2017 shows that with the interim closure of the Rehabilitation Unit, the impact on increased bed utilisation was minimal. The median bed occupancy between March and May 2016 was 62%, compared with 61% in In addition to this, the Winter Plan escalation procedures to manage a surge in hospital bed occupancy were used to manage safe elective and emergency patient care in the hospital 11 times in 2016 (between March and May). However in the same period in 2017, the escalation procedures were not required because overall acute bed occupancy did not exceed 36 at any time. The interim decision to close the Rehabilitation Unit has had a marginal impact on patient flow through Ward 3. The median occupancy level has increased from 68% to 71% and the number of times the ward has reached 80% occupancy has increased from 14 to 15. However, it is important to note that there have been very Page 6 of 19

11 few occasions where patients have been moved to other wards because of the lack of acute medical bed availability. Cancellation of planned procedures, including day care has also been kept to a minimum with support with patient placement from both the Day Surgical Unit and Ward 1. Given that the overall hospital bed utilisation remains low at 61%, we have not needed to open the surge capacity beds which are ring fenced to provide additional capacity if the hospital bed occupancy approaches 100%. The average length of inpatient stay in the medical, surgical and rehabilitation medicine specialties has also reduced in comparison with the same period in 2016 and our performance is now better than other hospitals in the peer group. Appendix B shows the comparative data for 2016 and A key driver for testing new ways of working and the implementation of interim measures was to safely manage the overall nursing vacancy factor across the hospital. Supplementary nursing staff help to maintain safe staffing levels where there is an increase in the level of patient acuity and to manage staff sickness absence. In December 2016, just less than 9% of the nursing capacity was provided by supplementary staffing (e.g. nursing working extra shifts on the bank). By May 2017, the percentage of shifts covered using supplementary staffing in the hospital had dropped to less than 4%. This is the lowest usage of bank staffing since May The tables in Appendix B show the shift in utilisation of supplementary staffing between June 2016 and April The reduction in supplementary staffing has also had a concomitant financial impact and reduction in budgetary overspends. Spending on supplementary nursing staff in the hospital setting between March and May 2017 has reduced by 56%, compared with the same period last year. 6. Wider impact of changes to older peoples care and success of joint working As a result of increasing the provision of community based services we have seen a decrease in the length of stay that older people experience in hospital and an increase in the number of people who can be cared for in the community as an alternative to hospital. Recently published reports show that we were the most improved health and social care partnership in Scotland as measured against a reduction during in the number of people who were medically fit but delayed in hospital waiting for a care package 5 (i.e. 56% reduction against the national average of 9%). Our performance for end of life care out with a hospital setting (i.e. Care in the community including 5 Delayed Discharges in NHSScotland Annual summary of occupied bed days and census figures. Figures up to March DelayedDischarges-Report.pdf? Page 7 of 19

12 the home setting) has been the best in Scotland for 2 years running 6 (i.e. 92% of people spent the last 6 months of their lives at home/in the community). Shetland has been on a journey for a number of years to providing more support and enablers so that people can carry on living at home, and in their communities. There is clear evidence that institutional care disables individuals, and the hospital setting should only be utilised for the longer term as a last resort. We have seen a positive shift through our reablement philosophy with people supported to remain at home, or enabled to return home as soon as possible after an illness (having stayed in hospital or a care centre). Where people cannot remain in their own home, because it can no longer be adapted to suit their needs; we have successfully supported people in alternative housing such as Brucehall Terrace and King Eric House, with their own tenancy which maintains privacy, dignity and independence. With a growing older population, and resources getting scarcer, from an efficiency perspective we must also continue to do work to prevent people needing to be admitted to hospital where it is right and safe to do so, and to support people back to independence after an illness. Had we not shifted the model of care already, Shetland would have been overwhelmed with demand and we would not have been able sustain safe, effective models of care. 7. Findings developing community based rehabilitation and impact on hospital and community resources Safe staffing levels have been maintained across the hospital, in order to deliver the necessary balance of emergency and planned care services; Services have been resilient throughout the winter period and since interim arrangements were put in place to provide community based rehabilitation. This is shown in a range of performance measures including access to emergency care through the 4 hour A&E target, cancellation of theatre procedures, length of stay in hospital, patients delayed in hospital and bed utilisation; The ICT has demonstrated that with additional resources committed by the IJB, it has been able to provide early supported discharge and an ongoing programme of recovery where people have been identified as meeting the criteria for ongoing reablement or rehabilitation; Patients and staff have reported that the development of the community based rehabilitation model has not had a negative impact on patient care and support in the community has been organised quickly and proficiently. Patient feedback on their experience of receiving input from the ICT has been positive; Staff who have been working in interim placements have made really valuable contributions to the teams that they have been supporting in both the community and the hospital setting. For example, this has enabled services such as Day Surgical Unit and the Out Patients Department to 6 Percentage of End of Life Spent at Home or in a Community Setting. Financial years ending 31st March 2010 to Life-Report.pdf? Page 8 of 19

13 manage increased numbers of ambulatory care patients and assist in the repatriation of services from NHS Grampian. Similarly, staff with experience of older people s medicine have supported community nursing teams and the ICT to increase its capacity. 8. Conclusion Through the implementation of the interim measures to move staff to cover nursing vacancies, we have ensured that there are safe staffing levels across the hospital and community setting; We have successfully provided non acute rehabilitation and reablement in the community as an alternative to the hospital based model; We have maintained and in some cases improved our performance, in comparison with the same period in 2016; We have demonstrated that we can effectively manage specialist, inpatient care and match capacity with demand via a hospital bed base of 44 Acute beds; We have reduced the overall cost of nursing staffing, particularly reliance on supplementary staffing between March and May 2017; We should therefore make a decision to permanently close the Inpatient non-acute Rehabilitation Unit. This will allow us to formalise the arrangements for new posts for the staff directly affected, and to make decisions on re-purposing the available space in the hospital. Page 9 of 19

14 Appendix A definition and origins of the ICT and Rehabilitation Unit The Rehabilitation Unit which is situated on Ronas Ward 7 was established in The Unit has six beds, is staffed 24/7 and admits patients from the hospital and the community who meet the criteria for non acute rehabilitation 8. Patients are then supported through a programme of time limited rehabilitation typically for 4-6 weeks but programmes can be longer and some are delivered over 6-12 weeks. The Rehabilitation Unit includes a team of Nurses, Healthcare Support Workers (HCSWs), Physiotherapists, Occupational Therapists, Therapy Assistants, Clinical Pharmacists and a Consultant Physician. The ICT was established in 2014 and includes a similar range of health and social care professionals to those working in the hospital setting - but this team has a current focus on re-ablement and early supported discharge from hospital in the community and is available as an extended day time service until 10pm. Appendix B key statistics to illustrate current service performance between March and May 2017 Bed Utilisation in the Gilbert Bain Hospital Table 1 Comparison of Bed Utilisation March to May 2016 & 2017 % Bed Ward 3 Utilisation Median Mean Max Min Occupancy > Table 2 Comparison of Bed Utilisation March to May 2016 & 2017 % Bed All Inpatient Beds Utilisation Median Mean Max Min Occupancy > Ronas Ward was relocated to the Gilbert Bain Hospital site in 2008, in 2014 when the Rehabilitation Unit was established then the remaining space was re-purposed to provide a Chemotherapy Unit and winter capacity planning beds. The services which are currently situated on Ronas Ward will remain insitu and are not subject to change. 8 A glossary of definitions can be found in the Intermediate Care Framework for Scotland, Scottish Government (2012), Page 10 of 19

15 Chart 1 Comparison of bed utilisation 2016 and 2017 Chart 2 Average Length of Stay in Key Specialties Jan-May 2016 (peer group comparison) Page 11 of 19

16 Chart 3 Average Length of Stay in Key Specialties Jan-May 2017 (peer group comparison) Chart 4 A&E 4 hour target performance from March 2016 to May 2017 (peer group comparison) Page 12 of 19

17 Chart 5 NHS Shetland A&E 4 hour target performance March 2016 to May 2017 Chart 6 Emergency Re-admissions within 7 days March 2016 to May 2017 (peer comparison) Page 13 of 19

18 Chart 7 A Delayed discharges from July 2016 to April 2017 Chart 8 A Chart to show bank nursing utilisation from June 2016 to April 2017 Table 3 Bank usage costs for Gilbert Bain Hospital only Timeframe Total Hours Total Costs 1 st March st May st March st May Page 14 of 19

19 Appendix C - Intermediate Care Team Performance (March May 2017) Referrals Referrals received in the time period above Month Number of Referrals Outcome March 1 Declined as no reablement goals April 10 Intermediate care Intervention 1 Falls Assessment May 2 Intermediate care Intervention Total 14 referrals 13 admitted to caseload for assessment/intervention Current position of the 14 individuals, Discharged from service following ICT intervention 3 Current caseload 10 Declined support - 1 Source of Referral Referrals were for made for the following reasons, across the time period as follows: Month Early Supported Discharge from Hospital Early Supported Discharge from Care Home Admissions Avoidance March 1 9 April May 3 Total This pattern of referral is reflective of the lower activity, and thus subsequent input required supporting hospital discharge and thus the increase in time spent on supporting discharge from a residential setting back to home. A small number of individuals (2) have also been supported at home and thus avoided an admission to hospital or a care setting. 9 Declined admission Page 15 of 19

20 Areas of Residence where Individuals have been supported Area of Residence Number of Individuals Lerwick 4 Bressay 3 Scalloway 2 Weisdale 1 Gott 1 North Roe 1 Mid Yell 1 Total 13 It can be seen that there is now an increase in the diversity of geographical areas being covered by the staff from the Intermediate Care Team. Age Profile Age Numbers of Individuals < 70 (68 & 70) years years years years 6 All individuals on the current caseload who are in receipt of an Intermediate care intervention are older people, with 46% of the current caseload being aged over 85 years. Page 16 of 19

21 Duration of Rehabilitation or Reablement Programme Time on Caseload Numbers of Individuals 7 weeks 1 6 weeks 2 5 weeks 6 4 weeks 1 3 weeks 2 2 weeks 1 An Intermediate Care Intervention generally takes place over a 6-8 week period. As can be seen all individuals on the current caseload are within this intervention time period. Outcomes In terms of Outcomes for the Individuals who have received Intermediate Care Team Intervention this can be demonstrated by reviewing individuals Dependency scores. Of the 3 patients who have been discharged, all 3 had a Dependency score less or maintained at the same level compared with the start of the programme. Readmission to Hospital or Care Setting post Intermediate Care Team Intervention Of the 13 referrals accepted onto the caseload, 10 are on the current caseload with 3 individuals having been discharged. There have been no readmissions of any of the 3 individuals who have been discharged. Of those still on the current caseload there has been no readmission to care or hospital to date. Declined Admission to Intermediate Care Only 1 individual was declined admission to the Intermediate Care service and this was due to the individual having no identified re-enablement goals. Page 17 of 19

22 Service User Feedback All individuals are issued with a service user feedback form at the time of discharge from the service. Results have been collated continuously and an overview of the comments received to date are included below. Strongly Agree Neither Agree or Disagree Disagree Strongly Disagree Agree 1. The Care I received met my own requirements I did not feel rushed or put under pressure Do you feel more able to cope on your own? Did you feel involved in the care you received I was kept informed each time my care plans changed Page 18 of 19

23 Appendix D Rehabilitation and ICT Pathway Page 19 of 19