DRAFT Rehabilitation and Enablement Services Redesign
Services Vision Statement Inverclyde CHP is committed to deliver Adult rehabilitation services that are easily accessible, individually tailored to assess needs, delivered locally where patients and carers need them. Services will be developed in conjunction with the views of carers to augment and support their role in rehabilitation. To achieve this commitment requires a shift in the way health and social care professionals work together and think with a review of skill mix and pathways of service provision to ensure they meet the challenges of a single integrated rehabilitation and enablement service which will deliver a community based service that delivers on an assessed needs basis. The Rehabilitation and enablement service will provide the same quality of treatment for all, regardless of age, culture or geographical location throughout Inverclyde CHP ensuring that patients achieve their maximum enabled potential.
1. Introduction The purpose of this paper is to discuss the design of Rehabilitation and Enablement Services in Inverclyde in order to develop cohesive, integrated and fit for purpose services. The document is based on national, policy and strategic drivers which have given direction to the proposed design of Rehabilitation and Services development. The Adult Rehabilitation Framework (Co-ordinated, Integrated & Fit for Purpose) aims to improve the experience and outcomes for service users and carers by addressing a number of elements of rehabilitation and enablement services which will be key to effective future service delivery The proposals within the document take cognisance of key areas of service development: Access to local services for patients and carers in partnership with their needs and wishes which reduces duplication Self management and Enablement services to allow patients to remain independent and prevent admission or re-admission to Acute services Supporting people with long term conditions Services that are structured and directed with clarity to make the best use of clinical services, staff and resources at the right place and time. Services that ensure equality for all residents of Inverclyde. Sustainable Multi-professional teams Comprehensive and evidence based services Capacity
2. Context The design of Rehabilitation and Enablement services has been driven by national and local documents which take into consideration and reflect the opinions of health, social work professionals, patients and carers: The Adult Rehabilitation Framework Towards a Community Rehabilitation & Enablement Service for Older People, Older People with Mental Health Problems and Adults with a Physical Impairment (NHSGG&C) Better Lives Better Health Enabling Health Integrated Visible & Accessible Changing Lives Care of Older People Long Term Conditions Strategy Carers Strategy Gaun Yersel Care Management Shifting the Balance of Care Living and Dying Well Corporate & Transformational Themes HEAT Targets Transformational Themes The fundamental aim of services is to maximise the potential of services to support patients with disabilities, older people, patients with mental health concerns and carers to maintain an independent lifestyle and minimise where possible hospital admission
3. Demographic Position Inverclyde is amongst the most deprived and disadvantaged areas in Scotland, with 42% of the population living in 20% of the most deprived areas in the country (Inverclyde Council 2008). Unemployment in the area stands at 3.8% compared to 2.6% nationally and employment rates are higher in some areas of Greenock and Port Glasgow, correlating with areas of high deprivation (Inverclyde Council 2008). Life expectancy for males is 70.9 years and 77.8 years for women, both falling below the Scottish average. In general mortality rates for the most common diseases, for example coronary heart disease and cerebrovascular disease, are above the Scottish average, as are rates for smoking and alcohol related disease and associated hospitalisation (Glasgow Centre for Population Health 2006). There has been an overall population decrease in Inverclyde over recent years, however the population of both those age 45-64 and those over 65 has increased and this is expected to continue. With this increase acknowledged, it will be essential to deliver services to support the care of older people in particular, taking cognisance of the rising age alongside the possible reduction in number of informal carers. Inverclyde CHP Demographics Age Population % 0-15 yrs 14,709 18.0 16-64 yrs 52,734 64.7 65yrs+ 14,097 17.3 Total 81540 (Source GCPH 2006) 4. Service Challenges
Within NHS Glasgow and Clyde the Rehabilitation co-ordinating group has ensured that local rehabilitation services are best placed to meet the challenges of shifting the balance of care and maximising services to achieve the high impact changes. Within Inverclyde multi agency events have taken place including all stakeholders to review the thinking behind Rehabilitation and Enablement with a consensus to develop services that are anticipatory and inclusive rather than past models of reactionary and periodic care. Current review of services both nationally and locally demonstrates a service with identifiable gaps around: Hospital discharge Robust patient pathways Use of SPARRA data to predict hospital admission Non integrated services with pockets of care Patient and carer confusion over services available to older people Professional lines of accountability In order to deliver safe and sustainable care, not only to the patients currently within primary care, but also to those patients who will be cared for in the community following re-provision of Ravenscraig, is the ability to deliver rehabilitation services in a consistent and equitable manner. An identified gap within primary care is at present the patchy and fragmented nature of Rehabilitation Services in Inverclyde due to the modes of investment in the existing rehabilitation teams. There is no identified resource from community nursing to any of the community rehabilitation teams in Inverclyde. Positive direction to address gaps within services will be the integration of adult nursing with other health care professionals and social work colleagues in delivering rehabilitation and enablement services within Inverclyde CHP. This ethos of seamless service delivery, with the development of care pathways, should ensure that patient centred care is effectively delivered through optimum use of resources, both financial and personnel. 5. RES Service Requirements
The aspiration for local services set out in the NHS Greater Glasgow and Clyde paper - Towards A Community Rehabilitation & Enablement Service, proposes the creation of a single, integrated rehabilitation and enablement service within each CH(C)P. The service should have the following characteristics A comprehensive assessment, rehabilitation and care management service delivery model within each CH(C)P available to meet the health and care needs of older people, older people with mental health problems and adults with a physical disability within the local structures. This includes residents of care homes. A community based service framework that delivers on an assessed needs basis across all care pathways A service that responds to the needs of adults returning home following hospital admission: delivering assessment, discharge arrangements, community based rehabilitation and ongoing care management A tiered level of service model, which targets specialist functions and resources at the highest and most complex needs, is flexible and able to respond to the changing needs of individuals and allows more direct access to resources at lower levels. A move from providing services on an episodic treatment approach to an approach with additional focus on rehabilitation and enablement. A stronger focus on supported self care and self management 6. RES Structure
To develop a structure that at its core is based on Rehabilitation, Enablement, defined outcomes and integration, it would be envisaged that a self management and rehabilitation service be developed under the general management model of a RES Manager. This will be developed using resources of existing mainstream services and existing teams but with a integrated communication structure and revised line management to allow effective and progressive development of the RES service. Fundamental to the success of the service will be the integration of services to allow a single point of access to be developed as well as clear referral and pathways of care which communicate with other agencies, General Practice and SPARRA data. Head of Health & Community Care Rehabilitation & Enablement Manager Self management Main Stream services Rehabilitation & Enablement Frail Elderly Team Frail Elderly Team PAS Team AS Specialist Nursing Specialist Local Enhanced Nursing Services Local Enhanced Services The RES element to the structure would be supported by a Team Leader with a remit to direct and locally lead the RES team but would report to the RES manager who would co-ordinate with the leads from Adult Services.
7. RES Service Model The RES service model is based on current developments within CHPs across NHS Greater Glasgow and Clyde to allow patients and cares achieve the best possible outcome to achieve independent living and prevent possible admission to hospital. INTENSIVE MAINTENANCE SUPPORT ENABLEMENT SELF MANAGEMENT 1 Self Management Sufficient information about the patient s long-term condition must be given with education and training at diagnosis with an on-going element to support the individual in managing their own condition. It is anticipated that the majority of patients will be supported by this model in self care with G.P practices and mainstream services supporting patients and carers to manage their condition through episodic care, health education and Information Technology. 2 Enablement
Ensuring adequate support and sign-posting to facilitate actualisation/maximisation of activities of daily living. 3 Maintenance Support Timely interventions to prevent deterioration, thus maintaining people in their own environment and preventing avoidable hospital admission. (Care co-ordination) Maximising potential through multi-disciplinary teams through care management Recognition of long term health and social needs that require support 4 Intensive Care management of complex cases with or without co-morbidity delivered by the most appropriate agency or discipline, following assessment. Time limited specialist interventions from RES Team and Adult Nursing Prevention of possible hospital interventions based on SPARRA information Robust and communicated hospital discharge Many residents within care homes will have long term conditions, and in order to provide equity of care, there should be no differentiation to the service this group of patients receive. Services must be accessible and suitable for everyone who needs them. Patients should have their needs assessed with the necessary input from the care manager and appropriate professionals. The use of a Single Shared Assessment approach should be adopted by all agencies concerned in the delivery of care to this group of patients/clients. This would require a single point of entry where an appropriate screening and allocation process takes place which would result in the patient being seen by the right person at the right time and in the right place. It is recognised that inappropriate admission to hospitals or care homes could be avoided if there had been early intervention of re-ablement strategies. An integrated approach across all agencies of health and social care will be required to achieve this outcome. Equity of service should exist, no matter where patients reside; ie. Own home, care home. Established links with Mental Health Services with Mental Health Services, will be strengthened and robust care pathways developed in order to support community practitioners to provide appropriate interventions and timely referral for clients with mental health needs.
The Single Shared Assessment process is used by local authority and community nursing. Carenap is used as core documentation. This will be reviewed in the near future as work is being carried out board-wide to refine the Single Shared Assessment process. The value of care planning cannot be under-estimated, with a move towards advanced care planning and anticipatory care becoming integral to an on-going assessment process. 8. RES Team Redesign The local vision of rehabilitation and enablement is that rehabilitation teams and the identified elements of community nursing and social work will integrate to implement the rehabilitation and enablement framework, to improve individual health status and concomitant morbidity. This will be achieved by: Effective use of resources (new and existing) Consultation with HR and Staff Side Representation Co-location of teams within Greenock Health Centre Joint working Joint training, e.g. Extended role training Encourage/Empower staff to reflect on their roles (Clinical Governance) Fostering a whole service approach Equality in access to health care Single Point of Access Single Shared Assessment General Management Function with Professional Leadership Culture Shift Care Management Training Development of the rehabilitation and enablement model affords an opportunity to promote seamless services, the integration of professional disciplines which could lead to a better understanding of the often diverse roles required to optimise the health of our patients. Several options are available to augment a multidisciplinary model: The transfer of the Frail Elderly Team from Rehabilitation and Assessment Directorate to Inverclyde CHP will allow a review of current custom and practice and resource utilisation to supply time limited rehabilitative interventions. The introduction of existing community
nursing posts to this team could be beneficial in changing the dynamics making the transition to new ways of working easier. The current Pass Nurses have an enablement role and may well be suitable to add to the new RES model. Two Nurse Specialist posts (COPD and Continence) and Local Enhanced Services for Diabetes also sit within this philosophy, both having rehabilitation and enablement responsibilities. A secondary consideration is this may ease the move of the gerontology nurse specialist to this team. Again depending on the nursing need within this team the elderly liaison role may be another valuable addition. Joint working with Social work Community Rehab Team The proposed redesign of RES services would include relocation of Community Rehabilitation Teams to Greenock HC to create a RES hub which is centrally located within the community of Inverclyde. This relocation will facilitate the communication network that is essential for integration of rehab services and remove the fragmentation of clinical services and risk of duplication of services which leads to confusion for patients and carers. The creation of a Rehabilitation and Enablement team with community would involve a move away from uni-disciplinary management to a general management model. To ensure continued staff and service development, professional leadership must be retained for this group of staff. An example of this model already exists within current services, i.e. Local Enhanced Services for Diabetes, with a multi-professional team being managed under a general management model but professional leadership still being maintained. This has proved to be a success in achieving integrated care for patients with this significant long-term condition and this model will be developed. It is important to note that as an integrated service, community nursing will be essential in the enablement of these patients when required. At present there is no identified nursing intervention within the Rehabilitation team however the redesign outlined will integrate community nursing into the multi-disciplinary service. To facilitate integration of community nursing with the existing rehabilitation teams, it is proposed that the community rehabilitation teams be supported by the appointment of geographical nursing and utilisation of the existing cohort of nursing assistants to join with existing community rehabilitation assistants. An essential part of this service will be the delivery of the rehabilitation and enablement agenda. This would support a more robust continued rehabilitation and would promote continuity of care over seven days whilst at the same time focusing resources on greatest need.
9. Proposed R&E Team Workforce Role wte Comment Team Leader 1 Band 7 New Post Physiotherapist 0.5 Band 6 AFC Review pending Physiotherapist 0.5 band 6 Rotational Role from IRH which Physiotherapy Support Worker Occupational Therapist Occupational Therapy Support 0.5 Band 3 AFC Review pending 0.5 Band 6 AFC Review pending 0.5 Band 4 should be consolidated Physio manager trying to make post permanent prior to transfer Worker Dietician 0.8 Band 6 AFC Review pending Speech & Language Therapist 0.55 Protected 8B Also does 12.25hrs PDRS Speech & Language Therapist 0.6 Band 8A Also does 3.75 hrs PDRS Inverclyde Clerical Support 1 wte Band 3 Podiatrist 0.5 Funding sits within Podiatry Budget LES 3 0.4 0f Podiatrist within Podiatry Budget (non LES clinical Time) PAS 3 35hr posts two from rapid response budget which lies with health, 1 from delayed discharge budget which we cross charge. 7.5 hrs from carers info budget fixed term for another two years also managed by health. Specialist Nursing 2 Continence & Respiratory Key CHP Resources Resources To Be Transferred to CHP In order to mange demand and capacity and develop the responsiveness of the current Frail Elderly Service to ensure timely and effective access to rehabilitation for older people, the following will require to be reviewed and addressed:
Identification of a team leader to promote general management model Standardised documentation in line with other professionals in the CHP including assessment tools. Referral pathway and review of interdisciplinary pathways Inclusion criteria Review of team structure Monitoring and Evaluation Co-location of Team to Greenock HC Integration of community nursing through redesign using geographical nurse Development of geographical Nursing Assistants extended roles to support rehab and enablement and a review of the existing support worker role in FET. This process will require discussion with the staff concerned, HR and staff partnership via the HR sub group of the Board wide Rehabilitation Co-ordinating Group. The CHP is committed to a robust Organisational Development programme with affected staff in order to plan, develop and implement a re-invigorated rehabilitation service. Rehabilitation Services for Adults with a Physical Disability Following the closure of Merchiston hospital and the associated implications for the existing Physical Disability Service, the CHP will need to work closely with the Rehabilitation and Assessment Directorate to conclude how this service can best be managed and integrated into the CHP in the future. This will be done via the Physical Disability Group. 10. Potential Future Actions The Rapid Assessment Team consists of an Occupational Therapist and Physiotherapist who provide rapid assessment of individuals attending A&E or those who have been inpatient for less than 72 hours with a view to avoiding admission or facilitating rapid discharge. There are clear, strong links with the hospital social work team in order to ensure access to adequate care packages to support the individual in the home environment. Short term rehabilitation can be supported for up to 4 weeks prior to discharge and during 2008 38% of individuals were followed up at home. In future it will be essential to support robust anticipatory care, care for those with long term conditions and rehabilitation needs that stronger links are forged between the CHP Community Rehabilitation Service and RATs. This will include for example, identification of at risk individuals via SPARRA and an awareness of care management arrangements in order to
continue to facilitate appropriate admission avoidance and timely discharge to the most appropriate service or practitioner. It is the aspiration of the CHP that this service will eventually be managed and integrated within its Rehabilitation & Enablement structure as this potential move will be the case within the rest of the health board area In addition to the current proposal there is scope through negotiation to add further specialties to the R&E team such as the Gerontology Nurse Specialist and Interface Pharmacist who would augment the integration of a rehabilitation and enablement team. Further development would be development of Generic Support workers rather than profession specific at present. 11. Facilitation Process To facilitate a robust, open and comprehensive implementation of the Rehabilitation and enablement team it is envisaged that a series of workshops incorporating all stakeholders will be organised in conjunction with Organisational Development to facilitate the process Workshop 1 Half Day facilitated Away day event Where are we, where do we want go? to inform mapping exercise of workload and systems. Workshop 2 Half Day facilitated Away day event Referral/pathways criteria to inform clear and concise systems that are fit for purpose. Workshop 3 Half Day facilitated Away day event The way Forward and review of process to inform multi-professional/agency integrated systems. 12. Information Technology Rehabilitation and enablement services will require to be underpinned and supported by the use of a fit for purpose information technology system which is pan agency in its communication links to ensure the development of: Electronic single shared assessment Use of SPARRA data to help predict risk of hospital admission Telehealth/Telecare to help patients and carers to maximise independent living 13. Evaluation
In conclusion, this proposal takes account of government policies, corporate themes and transformational themes, while progressing the equality of healthcare provision to the residents of Inverclyde, which can be evaluated: Equality Impact Assessments Long Term Conditions High Impact Changes Community Care Outcomes NHS HEAT Targets Efficient use of CHP resources 14. Proposed recommendations Mapping process to be carried out to evaluate current resources and identify gaps in service Review of team structure within current resources (including re-provision of Ravenscraig) Relocation of Frail Elderly Team to RES Hub within Greenock Health Centre Creation of Team Leader post (Band 7) for RES team to report directly to RES Manager Review of Nursing Structure - clinical and lead posts to support and link to RES team Multi-agency Referral pathway and review of inclusive interdisciplinary pathways Standardised collection of information standard documents in line with other professionals in the CHP. Robust and meaningful Monitoring and Evaluation 15. Equality & Impact Assessment EQIA is a vital part of NHSGGC s overall approach to dealing with inequalities and discrimination. It means that services, policies and projects are thought about carefully in terms of their likely impact on different groups of people and on the various aspects of inequality. The pre EQIA assessment was carried out within Adult Services to ensure this impact is analysed so that any negative effects on inequality and groups can be reduced and any opportunities for promoting equality can be maximised.