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Navigating Rehabilitation

Navigating Rehabilitation. Diana Halliwell Head of Continuing Care Central London Community Health Care Hammersmith & Fulham. Westminster PCT. Ealing SS. Westminster SS. H&F PCT. Ealing PCT. H&F SS. Hounslow SS. K&C PCT. Hounslow PCT. K&C SS. Hillingdon SS. Hillingdon

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Navigating Rehabilitation

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  1. Navigating Rehabilitation Diana Halliwell Head of Continuing Care Central London Community Health Care Hammersmith & Fulham

  2. Westminster PCT Ealing SS Westminster SS H&F PCT Ealing PCT H&F SS Hounslow SS K&C PCT Hounslow PCT K&C SS Hillingdon SS Hillingdon PCT H&F Continuing Care Service

  3. Team Administrator PA/YPD Head of Continuing Care Diana Halliwell Finance Manager Deputy Head of Continuing Care YPD H&F Assistant Finance Manager Health Care Manager YPD K&C/Westminster Information Manager Health Care Manager YPD Hillingdon Health Care Manager YPD Ealing/Hounslow Older People Health Care Manager Mental Health Care Manager Health Care Assessor YPD Older People Health Care Assessor Mental Health Assessor Team Administrator Older People/Mental Health H&F Continuing Care Team

  4. Aims of Service • Case Management from acute care through NHS or independent sector rehabilitation and into continuing care; • Making optimal use of resources to facilitate recovery and care by:- • facilitating discharge from hospital • avoiding admissions to hospital and residential care wherever possible • ensuring access to rehabilitation where necessary • complementing personal & social care packages offered by social services • co-ordinating access to health services where a range of professional expertise is required • increasing the flexibility of available health services and choices offered to clients • offering comprehensive tailor made continuing health care packages for clients meeting Continuing Care Criteria • ensuring cost effective service provision

  5. Referrals

  6. The Workload

  7. Acute Care/Neurosurgery Ward-based Therapy Reduced impairmentand pathology Goals and measures of outcome Post-acute inpatient Specialist rehabilitation HOSPITAL Improved activity(reduced disability) hOME Community-Based Rehabilitation Day Centre Out-reach/home based – Vocational Rehabilitation – Enhanced participation Longer term Community Support Specialist Case Management Maintenance of gains Review/drop-in clinics Re –access as required Care Pathway

  8. Hole Systems ! • A pathway full of potholes • The transition from acute to rehabilitation to continuing care never did run smooth

  9. Complex Specialist (Tertiary) NW LONDON NEURO REHAB RESOURCES Out of Contract TLU – RHND BDU –RHND Vent Unit – RHND St Andrews – Northants BIRT – Milton Keynes *RRU Northwick Park *BIRU Edgware RNOH Stanmore Pain Rehab SCIU *Queen Square (N.Central) *RHND (SW) Other Services Wolfson Frank Cooksey Blackheath Homerton District Specialist Rehab District Specialist Rehab Alderbourne Unit In and Out patients (Mostly Hillingdon) Robertson Centre Willesden Community Hospital (Brent) Neuro Rehab Unit Charing Cross (All PCTs) David Ferrier Unit Queen Square (K&C and Westminster) Local General Rehab Herrick Ward Northwick Park In and Out patients ( Harrow) Rehab Unit Royal Free In and Out Patients Clayponds Hospital In and Out Patients (Ealing) Athlone House Norton House In Patients (Westminster) Farm Lane In Patients (Mainly H&F) Community Teams with Dedicated Neuro-rehab component Harrow PDST Includes Neuro-therapists, Psychology & Rehab Cons. Westminster CRT Includes ABI, Neuro-therapist and Psychology Brent CRS Includes Neuro-therapists, Psychology & Rehab Cons. Kensington & Chelsea CRT Includes ABI, Neuro-therapist and Psychology Local Community Rehab Service incorporating Neuro-rehab elements Hounslow CRT Includes Neuro-therapists Ealing ARISE Includes Neuro physio Hillingdon CRT Includes Neuro physio Hammersmith & Fulham CARS Includes Neuro-therapist • RRU Specialist Community Outreach Service • Supports complex disability in the community including residents of specialist nursing homes • Working with general & specialist rehab teams • Specialist interventions e.g. botulinum toxin Key * * Main Tertiary Units which Specialised Commissioning have contracts with

  10. Finding the Right Placement ……… Outreach Epilepsy Outcomes Cost Follow-up Other Services Psychiatry Waiting List Aggression Ventilator Age Activity Clinical needs The Family Oxygen The Locality Speech Therapy Language Locked Unit Prognosis

  11. What Do We Want From Providers..?

  12. The issues THIS WAY

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