Commissioning & Delivering Re-ablement & Rehabilitation within a Social Care & Health

Organisation

National Home Care ConferenceMay 24th 2012

Sarah Shatwell, Associate Director Non-Acute & Social Care (B&NES Council)Stella Doble, Strategic Director, Adult Services (Sirona Care & Health)

Background & Context

• Building on commitment to early intervention & prevention

• October 2010, £70m made available for re-ablement activity, further £162m in January 2011

• Rising to £150m and £300m in 2011/12 & 2012/13• Made available via change in tariff arrangements for

acute hospitals• Allocated to PCTs but transferrable to LA• SW region early implementer project to develop policy

framework and detail of future tariff arrangements

Previous Focus & Definitions

• Intermediate Care

‘… a range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission and premature admission to long term residential care, support timely discharge from hospital and maximise independent living’

• Home Care Re-ablement

‘…seeks to support people and maximise their level of independence so that we can appropriately minimise their need for on-going support…re-ablement seeks to support a different phase on the continuum of care…a different stage of recovery…’

Doing Things Differently in B&NES…

‘In reality, the intermediate care and home care re-ablement phases for specific individuals may overlap’Considering widest possible definition of re-ablement across both statutory and voluntary sector

New Focus

• Truly integrated services• Broader offer • Significant involvement from voluntary & third sector• New settings of support • Stimulate partnerships • Evidence based

New Focus

• Three mapping & gapping analysis at RUH by DATE team (in-patient beds & ED)

• Expressions of interest for ‘Extended Research Pilots’• Emphasis on action learning and building evidence

base• Flexibility of offer

Extended Research Pilots

• Integrated health & social care re-abelment (Sirona & Way Ahead)

• Intensive Home from Hospital (Age UK)• Targeted Home Improvements (Care & Repair &

DATE)• Step Down Accommodation & Support (Sirona &

Somer)• Targeted Telehealth (Sirona)

Integrated Reablement

Service

Developing an integrated service Prior to July 2011:

• Social service provision. The Intake, Assessment & Re-enablement Team – centrally based covering the whole of Bath & North East Somerset.

• Primary Care Trust provision: Intermediate Care Teams – based in localities

Key service Objectives

• Prevention of admission into a hospital or care home

• Facilitation of planned discharge from hospital

• Planned rehabilitation and reablement

• Reducing long term care

• Supporting individuals in regaining independence

• Determining the appropriate level and type of service

for ongoing needs

Challenges involved • Importance of co-location• Need to understand roles and responsibilities • Development of relationships and shared

culture• Development of shared skills and competencies • Development of new ways of working and

alignment of working practices • Ensuring equal voice for health and social care

What we did• Co located teams into locality basis

• Developed integrated health and social care teams

• Held Joint work shops/ Cross shadowing

• Shared ethos and quality of services

• Shared roles to understand differences/similarities

• Agreed on new name for support workers - Reablement Therapy

Workers

• Shared performance reporting

• Shared documentation

Benefits of working together

• Improved communication • More flexible and timely response • Developing shared culture• Greater understanding of roles • Increased capacity through joint working • Simplified referral pathway • Greater opportunities for development and more

innovative ways of working

Vision for 12 Months

• To increase preventative work to reduce crisis

situations and deterioration in functional ability

• Widening offer – seeing people earlier to prevent need

for ongoing packages of care

• Forging stronger links with Mental Health Reablement

• Increase use of assisted technology – expanding

Telecare & Telehealth

Reablement Extended Research projects

• Integrated reablement service provided jointly with a domiciliary care agency to support people in Extra Care & residential care

• Stepped down accommodation, care & support provided jointly with a housing association

• Telehealth service to support people with heart failure to promote independent living