Integrated Rehabilitation Teams Enabling Risk Personal Outcomes Network

Integrated Rehabilitation Teams Enabling Risk – Personal Outcomes Network

Enabling Risk • any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury • Ref: WHO Enabling • supplying with the means, knowledge, or opportunity to do something • Ref: Freedictionary

Systems to “support” risk? Risk assessments Prioritisation frameworks Eligibility / Criteria Pathways

Taking the risk with service redesign in North Lanarkshire Rehab in off site beds Domiciliary Physiotherapy Community OT’s CARS

An Integrated Vision – Demonstrator Team • SALT • Dedicated Admin Community Rehab (CARS) Located together Community OT’s Central referral Off site bed Rehab • Pharmacy Domiciliary Physio Joint screening • Professional AHP support

The Rehab Sandwich Off site bed rehab Reablement Making Life Easier – self management Discharge to Assess D 2 A Rehabilitation

Discharge to Assess (D 2 A) • 2 AHP discharge coordinators – 1 per acute site. • Role – developing referral pathway and screening referrals, working jointly with Team Leads to arrange assessment and services. Home support Team Lead Equipment & Adaptation Service Rehab Teams Community alarm Acute discharge hubs Acute sites Discharge Coordinators

D 2 A Achievements March – August 2019 Criteria Why? • People are medically well, may still require care services and support to be discharged home. • Assessment is undertaken in familiar home environment. • More positive outcomes with family/carers more involved in assessments/planning. • Longer stays in hospital can lead to worse health outcomes • Risk of falls • Infection • Deconditioning • Reduced confidence • Reduce duplication in assessments • Improve hospital flow

Early Length of Stay Data Discharge with D 2 A Suitable but not discharged with D 2 A • Overall length of stay = 6. 3 days (average) • Overall Length of stay = 10. 9 days (average) • Average length of stay after referral to D 2 A = 1. 8 days • Average length of stay after referral to D 2 A = 7. 1 days

The Impact £££ 120 discharges – March - August Average 5 days less stay per discharge saved = 600 bed days

Impact – John’s Personal Outcomes • Chronic COPD – admitted with chest infection. Antibiotic treatment – stable. • Referred for D 2 A – arranged discharge for same day. • Assessment identified need for Care at Home, basic equipment, no long term need for community alarm. • Immediate rehab goals identified. • Care at Home was reserved from reablement team – quick feedback to confirm. • Outcome – 7 days – withdrawal of Care at Home and John back to his baseline. • John felt he improved quicker when he got home than when he was on the ward. • Less risk of hospital acquired infections. • Acute admission days saved.

Inreach Community responsibility to facilitate discharge back home. You’re in hospital lets start working on how to get you back home. The aim for discharge is everyone’s responsibility. What really needs to be done within hospital?

Better Outcomes • Home based assessments leading to more accurate goals and interventions. • More family involvement • Less over prescription of services and equipment.

Any questions?

Want to find out more? grahama@northlan. gov. uk Alison Graham @Alison. G 92303514

Exciting Horizons New work within Shotts Prison Service Dietetics linking with rehab teams Pharmacy in GP practices – medication re-alignment with home support services