Core Community Rookwood Lodge. YES - we provide a domiciliary physiotherapy service for these groups of patients.

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1 HBPR* CBPR** Community COPD team (CRRU) 1) Please whether there is a community rehabilitation service in your area for treating the following conditions: - Hip fracture - Stroke - COPD ES ES ES Core Community Rookwood Lodge ES - we provide a domiciliary service for these groups of patients. Vale Community Resource Service (VCRS) There is a community rehabilitation service in our area for hip fracture, stroke and COPD. There is not a specific service for each, although there is an Early Supported Discharge (ESD) service for Stroke, and a community respiratory service (CRRU). Most come to our team. Cardiff CRT ESD Stroke MSK OP Service In Cardiff & Vale UHB there are three geographically based, multidisciplinary, integrated health/social services Community Resource Teams (Cardiff rth & West; Cardiff South and East; Vale). They provide short term reablement services to people at home to divert them from hospital admission or enable them to leave hospital early. The teams include s, Occupational Therapists, Speech & Language Therapists, Dietitians, Nurses, Consultants and support staff from health as well as Social Workers, Registered Managers, Homecare Managers, Coordinators and carers from the local authority (plus admin staff). In addition, each team includes third sector support from either Age Connects (Cardiff) or the Red Cross (Vale), whose staff are based with the teams. Referrals can be made for any of the professions or services listed above or for a The Early Supported Discharge Service (ESD) provides multidisciplinary rehabilitation for patients who are being discharged from hospital following a new episode of Stroke. (By the definition below, ESD wouldn t be classed as a community rehab team as access to ESD is dependent upon confirmation of a new Stroke.) N/A

2 2) Please provide the patient pathway for accessing any services request one. Direct referral from respiratory physicians. Direct referral from CRRU. Primary care/secondary care referral to consultant led preassessment clinic. Pilot at present. Referral from cluster GPS and Practice nurses. Retrieval/screening on wards. Direct re-referral. GP/resp clinic/other AHP referral. We accept referrals from GP, Consultants, s, Hospital OT, Social Services OT, Social Workers, DN, Practice Nurses. For VCRS, all referrals are sent to the Central Communications Hub initially, either by fax, post or E-referral (hospital wards use E- referrals, GP surgeries refer via WCCG electronically). Any paper/fax referrals are then inputted on to Paris by staff in the hub. The referrals are then passed daily to VCRS, and we screen them as an MDT daily to ascertain which professions are required, and their priority. We receive referrals from hospitals, combination of them. Criteria for referrals is that they are over 18 and have a short term need for therapy/care to be provided in their own home to enable early discharge/divert from admission. Acceptance is not related to any diagnosis or condition though those who are at the end of life or whose needs are best met by a specialist service are unlikely to be appropriate for the service (e.g. palliative patients at end of life and those whose primary needs would be best met by mental health services) The service also includes a follow-on multidisciplinary Falls Service which provides longer term input to prevent and reduce falls in those identified as at risk. Referrals from the community are made via health professionals such as GPs District Nurses, Social Workers etc and are also accepted directly from care homes in the area Referrals from hospitals are made via wards using the electronic patient record After confirmation of a new stroke, patients are assessed by MDT members on the ward and a referral form is filled in. The referral form is then faxed through to the ESD office. Upon receipt of the referral form the ESD team will check that the patient meets the ESD criteria. If the referral is accepted, a member of the ESD team will contact the patient to make an initial. Occasionally, patients are referred to ESD following an outpatient

3 3) Please provide the waiting times for accessing any services request one. 5 month wait for consultant preassessment clinic week wait for PR. Pilot at present so wait of up to 3 months due to provision of 4 courses a year. waiting time. We have an urgent W/L for acute conditions e.g. post d/d, post surgery etc generally 4 weeks maximum wait. Our routine list is a maximum wait of 14/weeks. clinics, GPs, Social Workers, Care Homes, 3 rd sector services, District Nurses, and any other Health or Social Care service Waiting times vary depending on which professions are required and the needs of the patient. We have the capacity to respond to emergency/urgent referrals the same day if it is to prevent a hospital admission. Patient discharged from hospital into our care service currently have an average response time of just under 4 days. Our Nurses can respond to all urgent referrals within 24 hours. In Physiotherapy, we currently respond within 3 days to urgent referrals, and 7 days for routine. The standard response times for people in hospital whose discharge is dependent on them having care combined with therapy at home is 3 days from referral. Response times for people in hospital or at home who require input from health professionals but no care are triaged and prioritised according to need. Same day response can be provided to enable urgent support to prevent admission. with a stroke consultant. These patients have frequently been misdiagnosed as a TIA and have residual symptoms but have had no previous access to rehabilitation. Waiting times for vary and are dependent upon current caseload and staffing. Patients are generally seen within 2 4 days following receipt of referral. These patients may be seen earlier by other members of the MDT If a patient is being discharged with carers from the Community Reablement Team (CRT), then either a physiotherapist or occupational therapist will attend on the day of the discharge to complete a joint visit with CRT care manager / co ordinator. Subsequently, this group of patients have less of a waiting time for.

4 4) Please whether patients can be a) re-referred into or b) self-refer back into any services request one N N - we do accept re referrals and R/V the suitability of those referrals on a case by case basis as to whether it is appropriate for another visit. Patients can self refer back and following any discussions with the patient, we would offer another or ask them to be referred by a GP if there any new medical problems. - patients can be rereferred. Patients can self refer for Homecare Reablement services (care packages), but not for therapy only packages. If they attempt to do this, we advise them to seek a referral from their GP. referral is via a health professional/care home/sw. Patients are unable to self refer back into the Patients can only be re -referred if they have been diagnosed with a new Stroke since the last episode. Occasionally a patient may have had to be hospitalised for a short period whilst they are receiving input from ESD, in these cases the patient can continue with ESD when they are discharged back home. 5) Please provide details of the staffing make-up of any services request one. 6) Please that patients can access MSK 0.4 band 7 physio 0.2 band 6 physio 0.6 band 2 physio assistant 0.6 band 2 support staff 0.6 band 7 OT 0.5 band 5 dietitian 0.2 band 6 physio 0.2 band 7 OT 1 wte band 7 physio 1 wte band 7 OT 4.9 wte band 7 nursing 1 wte support staff Band WTE. Band WTE. Tech WTE. MDT service of Physio, OT, Nursing, Dietetics, SALT, Social Workers, Admin, Rehab techs, Reablement Support Workers, and the British Red Cross sit within our team and office for us to work with. n/a n/a n/a n/a n/a n/a Cardiff CRT health staff: s; Occupational Therapists; Speech & Language Therapists; Dietitians; Nurses; Consultant Geriatricans; Profession specific techs (Physio/OT/SLT and Diet); Rehabilitation Assistants; Administrative staff. Cardiff Council Staff: Social Workers; Registered Managers; Homecare Managers; Homecare Coordinators; Home Carers; Administrative staff. Third sector: Age Connects 0.8 WTE Band WTE Band 7 4 WTE Band 3 Rehab Techs

5 through each of the following pathways: - By referring directly to the service and being given the details to book a who arranges the referral to the practice - Other (please provide details) - In the process of planning a pilot project to roll out self referral and being given the details to book a who arranges the referral to the practice (pilot currently in 1 GP practice) 7) Please that patients can access for their existing long-term condition through each of the following CRT is not a physio specific Patients who need a multidisciplinary, home based service, which can include, can be referred to the team.

6 pathways: - By referring directly to the service es We can accept a referral directly from the patient, but we will speak to the patient to decide whether we will need referral from GP if more than 12 months has elapsed or if there has been any changes to the patients health. Any one from Question 2 can arrange the referral., they cannot refer to Physiotherapy in VCRS, but they can seek a referral from their GP into our service - In the process of planning a pilot project to roll out self referral and being given the details to book a and being given the details to book a who arranges the referral to the es es es, the GP can refer them to our service, we would then contact the patient to arrange an for them. es a GP can arrange a referral to the physio I believe a few GP surgeries may have physios within them. who arranges the referral to the practice (pilot currently in 1 GP practice) practice They could be referred into VCRS physio by any other healthcare professional, care home or 3rd sector - Other (please provide details) * hospital based pulmonary rehab ** community based pulmonary rehab pilot

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