A collaborative approach to rehab, reablement , recovery, survivorship & prehab in the SW

1. A collaborative approach to rehab, reablement, recovery, survivorship & prehab in the SW Ruth Hall, Quality Improvement Programme Manager SCN August 2014

2. Purpose For system stakeholders to work with the SW SCN on plans to develop a single commissionable rehabilitation pathway in the South West that is focussed on: The understood needs of people. Safe, high-quality care that reflects learned good practice and makes the best use of scarce resources. Equity and consistency. Transparency for patients

3. By Address ad hoc nature of service Great synergy across services People centred/transparency Outcome focused Optimise potential of proactive rehab in following areas: managing of LTC care management after sudden onset incident living with and adjusting to impact of illness and/or injury

4. South West Pockets of best practice All condition specific Historically worked in silos So why change it? It is a priority People are living longer and rarely have 1 condition Not all our patients getting the right rehab Balance between specialist and generalist therapy not meeting the need But enthusiasm in SW to improve services

5. How is it being moved forward?- what has been done SW Project Group Clinical champions & clinical lead Two half day pre-meets in May 2 day event 1st and 2nd July Multi agency – LA/Health/PH…. Learn from forerunners in SW ie South Gloucs, Symphony, Pioneer Projects

6. How is it being moved forward? cont. • Now in implementation stage • Circulate pathway to SW as output of event • Take up offers of help for the work stream from 1st & 2nd– project groups/work streams • In September write to commissioners: • with the pathway for inclusion in the commissioning intentions • pull out what is distinguishable about this pathway • what still needs to be done – costing the pathway, tools to support commissioners,

7. The things we think need to be done Programme Group 1 Performance and Finance: refine and cost the core pathway, establish the business case (showing how money follows the patient across the system) In Jul when our joint session has established a core rehabilitation pathway that has been developed by (and is now owned by) the SW system 2 OD: Develop a system / organisational design that supports equity and consistency in future commissioning Evaluation of the pathway In 3 years, when the changes we are planning for rehabilitation have been fully implemented and bedded in Communication and Consultation: engage and align the whole integrated system / supply chain 3 Governance and Programme Management: Lead and manage the programme, constructing the compelling case for change 4 5

9. The person-centred rehabilitation lens Self-management Continuous assessment and improvement Sustainability Carer views Acute / community in-patient rehab plan Complex home rehab plan Monitoring Innovation Personal Joint, collaborative assessment of need, options, choices, outcomes, incentives, management Managed conclusion of formal rehabilitation care and support The person, their carer and family in their community First single POC Rehab Plan Technology Feedback Home rehab plan Education Incentives Re-assessment

10. Thank you for listening Any questions? How would you like to be involved and kept informed? Ruthhall@nhs.net 07796 994459