Best practice for community living through Intermediate care and reablement: A complex case discussion. Fiona Howlett May

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1 Best practice for community living through Intermediate care and reablement: A complex case discussion Fiona Howlett May York St John University 1

2 Plan for the session Brief summary of intermediate care and reablement Discussion around complex case scenario Implications for the work/resources required 2

3 What is Intermediate Care? Intermediate care is a range of integrated services designed to: promote faster recovery from illness prevent unnecessary acute hospital admission and premature admission to long-term residential care support timely discharge from hospital and maximise independent living. 3

4 Essential elements within Intermediate Care Services are locally based Multi professional/multi agency teams Care provided close to home Services are short term Focus is on restoring or maintaining function Rehabilitative approach 4

5 Key drivers for the development of Intermediate Care Pressure on acute hospital beds NHS financial pressures Local authority financial pressures More older people with long term chronic conditions Patient choice Reimbursement 5

6 Intermediate care services are based on: Comprehensive, multi professional, multi agency assessment - in line with the single assessment process (DH 2001) Provision of a structured individual treatment plan which includes active therapy, treatment or opportunity for recovery. 6

7 How is Reablement different to Intermediate Care Services? Services for people with poor physical or mental health to help them accommodate their illness by learning or re-learning the skills necessary for daily living. (Care Services Efficiency Delivery programme 2007) Helping people to maximise their independence, choice and quality of life Helping people to remain in their own homes 7

8 Reablement Providing time limited interventions with services tailored to individual s needs (Care Service Efficiency Delivery programme 2007 Reablement seeks to maximise long term independence, choice and quality of life, whilst minimising the ongoing support required Pilkington 2008 p

9 How does this differ from Intermediate care? Hospital (secondary care) Intermediate care (may be primary or secondary care depending on location) Reablement (Predominantly Social care) 9

10 Guiding principles Person-centredness: Service users should have more control and choice over their support The role of adult social care is to help people to maintain or regain their independence, regardless of age, impairment, ethnicity or personal circumstances 10

11 Mrs Brown Mrs Brown is a 68 year old woman Until recently she had shared her privately rented terraced house with her partner of 20 years Partner had recently died in traumatic circumstances and she was coming to terms with her loss 11

12 Presenting Medical Issues Chronic lymphodema affecting both legs. Both legs are ulcerated and require daily dressing Osteoarthritis affecting both hips and knees Obesity 12

13 Social Support systems No family Two good friends who live locally Mrs Brown does not know neighbours as neighbouring properties also rented and neighbours change frequently No help at home other than District Nurses who visit daily to dress Mrs Brown s ulcerated legs 13

14 Presenting problems and reasons for referral Referral to the Intermediate care team by the District Nurses Presenting difficulties were: She was not able to mobilise safely around her home She could not access her toilet She could not access her bathroom She could not access her kitchen 14

15 Presenting problems continued.. Mrs Brown s house was very cluttered and inaccessible There were dogs, a cockatiel, two snakes in a vivarium and mice running around the property Basic needs were met at ASDA (Wal-Mart) via scooter Risks

16 Street of terraced houses 16

17 A fairly typical terraced house 17

18 Narrow hallway 18

19 Narrow stairs 19

20 Dining room 20

21 Galley Kitchen 21

22 Sitting Room. York St John University 22

23 . York St John University

24 What did the team do? Responded to the referral within 2 hours and completed a risk assessment Admitted Mrs brown to an Intermediate care team bed in a local nursing home. Contacted environmental health department to remove the dead mice and put down bait for the living mice RSPCA took away the snakes and arranged foster care for the dogs and a friend looked after the bird in the cage 24

25 Mrs. Brown s Goals To be able to get washed and dressed with minimal assistance To be able to access the toilet and get on /off the toilet safely To be able to prepare meals safely To be able to mobilise around her home safely To live in a property which meets her needs and in which she feels safe 25

26 Ethical Issues/ Diversity of living conditions? Some individuals may stray from societal norms of cleanliness and hygiene What are the ethical and practical issues for professionals? How can you respond to the challenges? What are the potential solutions? Would you offer Mrs Brown any interventions, and if so where? 26

27 Ethical issues in practice There is an ethical dimension to most of what we do in the workplace (Hendrick 2004). Professionals need to be able to recognize these and consider the implications for the individual, their families and carers. Campbell, Chin and Voo (2007) identify that medical ethics is not the concern of one professional group or discipline but is a matter which should be approached from a multi-disciplinary perspective having relevance to all professionals working in health and social care. 27

28 Resolving ethical dilemmas Informed by professional codes of practice It has been argued that Codes of conduct should be used as a framework for guidance but cannot be expected to resolve complex ethical dilemmas (Terry 2007). Supervision Multi disciplinary team discussion Grids/frameworks/models may help but need to remember that applying ethical decision making models does not produce bias free decisions as personal values will still impact on upon this process (Mattison 2000) 28

29 Need to consider.. Balancing risk with harm Positive risk taking Respecting autonomy and choice 29

30 What Model of practice might you use and why? 30

31 Person-Environment-Occupational Performance Model Person Environ ment Perform ance Occupation Baum, Bass, Christiansen (2005) 31

32 Person Level issues Health Strengths Needs Goals Wishes Meanings Risks Occupation Activity task role What/How/when Supports Preserved activities Bingo/social outings Risks Benefits Occupational Performance Community engagement Environment Where/Who with? Supports Demands/ Home environment Risks Benefits 32

33 Canadian Model of Occupational performance and engagement Townsend and Polatajko

34 Canadian Model of Occupational performance and engagement Self-care Washing/dressing Showering Toileting Leisure Walking dogs Going to bingo Social events risk of social isolation Productivity Preparing meals Maintaining home 34

35 Person centred assessment Use active observation Standing back allowing person to be themselves and be in the flow of activities Observe the person s own strategies, routines and pathways and build on them Use activity analysis and synthesis Mixed methodology - Informal, formal, standardised and dynamic 35

36 Person centred assessment Working with the person in their lived environments: Physical environment creating accessible and enabling environments, role of assistive technology and adaptations Social and cultural environment Reducing stigma Reducing occupational deprivation Promoting positive communication Supporting and enabling carers 36

37 Which assessments would you choose and why? 37

38 Assessments Observation of Activities of daily living FIM/FAM (base line) Granger et al (1993) COPM (Law et al 2005) AMPS (Fisher 2003) Homefast (Mackenzie et al 2000) 38

39 What interventions might you choose and why? 39

40 What interventions and why? Maintain or improve upper/lower limb strength, ROM and tolerance Maximise ADL Ensure safety and accessibility in the home - Rehousing Assess need and make recommendations for equipment/adaptations Explore interests/reduce social isolation Assist with psychological adjustment to problems 40

41 Who was involved? District Nurse Physiotherapist General Practitioner Consultant orthopaedic surgeon Therapy Assistants Dieticians Environmental Health Officers Local Housing Department Friends Foster carers for the pets 41

42 Outcome Mrs Brown was re-housed within 8 weeks to a local Housing Authority owned bungalow which already had a level access shower A hoist was provided for the days when Mrs Brown s mobility was severely impaired by pain 42

43 Outcome Mrs Brown required bariatric equipment to meet her needs: Wheelchair Shower chair Rise recliner chair Profiling bed Glideabout commode 43

44 Outcome Mrs Brown received a package of care which involved carers visiting 4 times each day to assist with personal care, meal preparation and walking her dog - provided free initially for 6 weeks Transferred to reablement team then to private care team then she would need to pay for her care through Local Authority Her dogs and budgie were returned to her The snakes were not! 44

45 Implications for work/resources Services are free at the point of delivery Response times 2 hours from receipt of referral Therapy services 7 days per week Extended hours of working Services are time limited to 6 weeks Services are provided close to home or in the home Collaboration with the older person and their carers essential Collaboration with other team members essential Role blurring common 45

46 References Baxter S & Brumfitt S (2008) Professional differences in interprofessional working Journal of Interprofessional Care 22 (3) Campbell A, Chin J and Voo T (2007) How can we know that ethics education produces ethical doctors? Medical Teacher 29 p Baum C, Bass J, Christiansen C (2005) Person- environmentoccuaptional performance: a model for planning interventions to individuals and organizations. In Christiansen C, Baum C, Bass J (Eds) Thorofare. New Jersey.Slack inc. DH (2000) NHS Plan. London: The Stationary Office. DH (2001) National Service Framework for Older People. London: The Stationary Office. 46

47 References DH (2005) National Service Framework for people with long term conditions. London: Stationary office DH (2009)Intermediate Care: Half way home London: The Stationary Office Fisher AG, (2003a) Assessment of motor and process skills 5 th edition. Fort Collins,CO. Three Star Press Glendinning C,(2003) breaking down the barriers: integrating health and social care for older people in England. Health Policy 65 (2) Granger CV, Hamilton BB, Linacre JM, Heinemann AW, Wright BD (1993). Performance profiles of the functional independence measure. American Journal of Physical Medicine and Rehabilitation. 72(2),

48 References Hoffman SJ, Rosenfield D, Gilbert JHV, Oandasan IF (2007), Student leadership in interprofessional education; benefits, challenges and implications for educators, researchers and policymakers. Hughes L, Marsh L and Lamb B (2006) Creating an Interprofessional Workforce Hammick M, Freeth D,Copperman J, & Goodsman D (2009) Being Interprofessional. Cambridge. Polity Press Hendrick J (2004) Law and Ethics. Foundations in Nursing and Healthcare. Cheltenham. Nelson Thornes. Law M, Baptiste S, Carswell (2005) Canadian occupational performance measure. Toronto. CAOT publications. 48

49 References Mackenzie L,Byles J, Higginbotham N, (2000) Designing the home falls and accident screening tool. (HOMEFAST): Selecting the items. British Journal of Occupational Therapy 63(6), McDermott K, Linahan K and Squires B J (2009) Older People Living in Squalor: Ethical and Practical Dilemmas Australian Social Work Vol 62, No 2 pp Northern health (2004) Patients first: Optimizing Inter-professional Team Work. Report on current practices. Prince George, BC, Northern Health project Pilkington, G (2008) Home care reablement: Why and how providers and commissioners can implement a service. Journal of Integrated Care. 16 (2)

50 References Terry L (2007) Ethics and contemporary challenges in health and social care. In Leathard A and McLaren S (eds) Ethics and contemporary challenges in health and social care, pp 25 Bodmin: The Policy Press Townsend,EA Polatajko,HJ (2007) Enabling occupation 11: Advancing an occupational therapy vision for health well-being and justice. CAOT publications ACE. Ottawa ON. Seedhouse D (2005) The Moral Context of Practice and Professional Relationships, In Occupation& Practice in Context Whiteford G and Wright-St Clair (Eds) Australia Elsevier 50

51 Programming with elders: A summary Fiona Howlett 51

52 Summary: Programming with elders Or, interventions with older people Services driven by Department of Health policy guidance Services driven by ageing population Services are designed to meet the needs of local populations There is not always a blueprint for how services should be delivered Freedom to be able to work in a person centred way with an older person Interventions are focussed on the older person s goals Services remain free at the point of delivery Services are time limited 52

53 A thought to leave you with.. Older people must not be left to find their way around the hospital system or left in a hospital bed when supported care or rehabilitation is what they need They must receive the right care in the right place at the right time. NHS Plan DH (2000) 53