A Delivery Framework For Adult Rehabilitation

1. A Delivery Framework ForAdult Rehabilitation Future Vision of Rehabilitation Services What do we need to do to meet the challenge? www.rehabilitationframework.scot.nhs.uk Sarah.mitchell@scotland.gsi.gov.uk

2. Key messages • Integrated working across professions and agencies • Innovative approach to service delivery • Focus when re-designing services on patient journey • Measure the impact

3. Better Health, better Care Changing lives Review of Nursing in the Community An employability framework for Scotland Shifting the balance of care Joint Futures / Joint Improvement Team – Intermediate Care HEAT targets SPARRA Community Hospital Strategy CHP Toolkit Mental health delivery plan National Strategy for LTC’s Supporting self care Better outcomes older people + national strategy Health inequalities task force 18 week targets National outcomes framework for community care Patient Experience Programme Links with other Scottish Government work streams

4. Challenges for Framework implementation Move away from a reactive, unplanned and episodic approach to rehabilitation Re-design of services to ensure this can be achieved True integration of community rehabilitation teams and local authority teams Provision of earlier interventions for those individuals going onto sickness benefit Develop case / care management approaches within integrated rehabilitation services

5. Key RequirementsCo-ordinated and Integrated • Service user focused • Single point of access into rehabilitation services • Shared documentation • Integrated social and health care teams delivering prevention, self management and enablement – reducing transitions of care • Case / Care management approaches

6. Key Requirements –Co-ordinated and Integrated • Fundamental shift in how and where we deliver services – focus needs to be on prevention, self management, early intervention and enablement • Recognising, harnessing and developing skills of health and social care practitioners • Utilising and developing technologies to underpin new services • Improving the evidence base around rehabilitation services • Measuring the impact

7. Older People’s Services • a better life for older people in Scotland, now and in the future • supporting older people to live healthy independent lives • supporting active ageing and promoting positive attitudes towards ageing • valuing older people and supporting them in continuing to contribute to Scottish society

8. HDL – Falls for CHP’s • NHS Boards need to have a combined falls and bone health strategy which CHP will implement • CHPs need to appoint a falls prevention lead or coordinator to work along side the rehab coordinators • CHPs need to develop an operational falls prevention and bone health implementation strategy targeted at those for whom there is evidence that effective intervention will reduce the risk of future fractures and falls.

9. HDL – For Hospital Settings • Protocols are in place to ensure falls risk minimisation; • A systematic process is in place for the management and prevention of falls; • Appropriate falls awareness education, support and guidance is provided to all staff, regardless of their role in the hospital, where patients may be at risk of falling; • Accurate recording and reporting of incidents, including falls, are reported through the incident reporting procedure; and

10. Progress to date!

11. National ImplementationGroup • Representation from: Patient rep, SWIA, Changing lives team, health, housing, AHP, SSA team, Scottish Govt reps, Community Planning Partnerships • Remit – advisory, a forum to support shared learning and emerging good practice, monitoring the impact of implementing the recommendations • 4 meetings to date. Updates published on www.rehabilitationframework.scot.nhs.uk

12. National Implementation Plan • 5 High Impact Changes – with improvement actions and time scales and explicit links with: • HEAT targets • Community Care Outcomes • National Performance Framework; National Outcomes • Single Outcome Agreement

13. Opportunities for health promotion, self management, on-going rehabilitation and maintenance are maximised, using for example community centres and other leisure facilities. These facilities are readily accessible by local transport • enhance opportunities for the population to keep fit and active. Recognising the health gain and social engagement benefits of using mainstream leisure facilities for health promotion and rehabilitation • build on existing good partnership, working with the voluntary sector to develop accessible information for users and carers and professionals on self management support and rehabilitation services available in local areas. • work in partnership to facilitate the development of suitable local transport for rehabilitation purposes. Falls – supported active aging – minimising the risk of falls and low trauma fractures – accessing appropriate services

14. Health and Care Pathways provide single point of access for rehabilitation services. This will be supported by appropriate tools for screening, triage and assessment and information on availability of services with a focus on improving service user experience. • enhance access to services, information and sources of support for individuals requiring uni-professional and multi-professional rehabilitation, including:  • developing a single point of access to services. • introducing direct access to services • Utilising NHS 24 as a resource for information, advice, triage and access to rehabilitation • Access for individuals living in care homes • Utilising the Comprehensive Geriatric Assessment (CGA) for older people whether in the community or in acute hospitals •  Utilising the SSA Falls – early identification, ambulance, NHS24, A+E, in-pt services, dexa services, community alarms

15. Older people and people with long term conditions are supported to live in their local communities with the appropriate integrated rehabilitation / enablement services. • integrated approach to rehabilitation / enablement services can be developed to meet the needs of the growing number of older people, people with long-term conditions and those with specialist rehabilitation needs. • identify how anticipatory care and rehabilitation services can be focussed on “at risk” / vulnerable individuals to provide early intervention, prevent unnecessary admissions to hospital or care facilities and facilitate smooth transitions from hospital or specialist services • linking together early intervention/rapid response services with community rehabilitation teams, specialist rehabilitation and nurse/therapist led units, community hospitals and integrated care to provide seamless transitions of care.

16. NHS Quality Improvement ScotlandFalls Programme (Dec 2007-Dec 2009) Falls Community of Practice • CH(C)P Falls Leads sub-group • Online Falls Communitywww.fallscommunity.scot.nhs.uk • New resource: Up and About: Pathways for the prevention and management of falls and fragility fractures (available in electronic format Summer 2009)

17. Falls community of practicewww.fallscommunity.scot.nhs.uk Exchange knowledge, ideas, experience and good practice Find useful resources Access pre-programmed searches Find and contact colleagues Discuss topics of interest

18. NHS Quality Improvement ScotlandFalls Programme (Dec 2007-Dec 2009) • The development of data standards for falls, in partnership with the National Dataset Development Programme, ISD • Promoting a consistent approach to the development of falls training programmes for health and social care staff in Scotland, in partnership with NHS Education for Scotland • The development of : • an fact sheet to assist services in identifying older people at high risk of falling in the community (September 2009), and • recommendations for the use of clinical outcome measures in the management of older people who have fallen (consensus development meeting September 2009).

20. Care Commission – Inspection 2009/10 • Inspection Focus Area on ‘Meaningful Activity’ the Care Commission is supporting the priorities outlined in the Health Department Letter (HDL) (2007) 13, issued in February 2007. • Supported by appointment of Rehabilitation Consultant within Care Commission

21. The Care Commission aims to ensure providers are: • Aware of the Scottish Government policy and strategic direction • Regularly carrying out falls risk assessments • Taking action to minimise the risk of falls and the consequence of falls, including fracture • Aware of the contribution of other professionals, services and agencies

23. NHS 24 – PhysiotherapyTriage • Single point of access into PT. Improving access to services (especially for remote and rural areas) • Reduce waiting times • Improve patient experience and patient safety • providing cost efficiencies • introducing new and different roles for AHP professionals.

24. MSD Website Development • review the contents of the Working Backs Scotland website • explore the development of an additional website relating to Upper Limb and Neck conditions • investigate if these websites could form part of a suite of MSD sites including the existing ‘NHS Lothian knee website’

25. Useful web adresses • www.rehabilitationframework.scot.nhs.uk • www.enablinghealth.scot.nhs.uk • www.fallscommunity.scot.nhs.uk • www.ltcscotland.wiki.is