south gloucestershire rehabilitation, reablement & recovery programme
TRANSCRIPT
Aim – To redesign rehabilitation, reablement and recovery services in South Gloucestershire to create a pathway which is focussed on:
The understood needs of people Safe, high quality care that reflects good practice
and makes the best use of scarce resource Equity and consistency Transparency for patients
What is the 3Rs Programme?
What is the 3Rs Programme?
More rehabilitation is undertaken in the community
Patients will have improved continuity of care Reduce the time patients spend in an acute
hospital setting Reduced need for long term residential care Improved outcomes for people
Objectives
Objectives
People:
Will know what to expect and will be able to recognise and describe their needs, now and in the future
Able to take informed risk about their own care.
Will get support 24/7 Will be empowered and listened to
What will success look like?
Success Criteria
Carers:
Able to refer to one plan of care that is person-centred; that provides continuity of care; and that recognises the needs of the carer
Feel less burdened, marginalised and ignored Feel more comfortable with their
responsibilities Get useful advice and information Have access to carer support Feel valued, recognised and heard
What will success look like?
Success Criteria
Staff:
Social care and healthcare professionals have access to: Coordinated and managed services. ‘Wrap around’ services, covering all conditions. Specialist services
Feel that people have been able to make informed choices
Have access to a shared, trustworthy, electronic person database
Know what is achievable and what is not Work in a culture that supports partnership, rather than
paternalism
What will success look like?
Success Criteria
Acute & Community Services:
Recognise clear, understandable, individually-funded pathways for the whole person journey, including agreed outcomes with clear rewards and penalties
Can move care to the community with confidence – can ‘push’ while community ‘pulls’
Fewer unnecessary admissions, less extended LOS – better and more reliable ‘flow’ across the system
Consultants are more willing and more confident to reach out into the community
Have access to a shared, trustworthy, electronic person database Community Services will take care over from acutes, with
confidence, once people are clinically, physically, mentally and emotionally stable enough
What will success look like?
Success Criteria
The Person Centred Rehabilitation Lens Personal
Rehab Plan
Managed conclusion of formal rehabilitation care and
supportThe person, their carer
and family in their community
Joint, collaborative assessment of need, options, choices, outcomes, incentives,
management
First single
POC
Acute / community in-patientrehab plan
Complex home rehab
plan
Home rehab plan
Educatio
n
Re-assessment
Monito
ring
Feedback
Incentives
Self-management
Carer views
Innovati
on
Tech
nolo
gy
Sustain
ability
Continuous assessment
and improvem
ent
Continuous assessment
and improvem
ent
There are two broad phases to this programme:
Phase 1: Describes current work to move towards the new model of care using opportunities as they arise to reshape services. This provides an opportunity to test and learn through evaluation of these projects
Phase 2: This is the main phase for implementing the 3Rs model and includes the commissioning of long term arrangements for community rehabilitation services at Thornbury and Frenchay respectively
Implementation
Governance
Phase 1
There are many things that are already in development as part of Phase 1:
Developing a new model of community services centred around local clusters of GP practices
Improving flow through acute hospital through developing a single assessment process for patients and case managers to help navigate patients through the system
Commissioning community rehabilitation beds in nursing and residential homes, and associated support
Developing a new approach to reablement, focusing on supporting individuals to remain as independent as possible
Refining the provision of sub acute rehabilitation at Henderson Ward, Thornbury and Elgar House, Southmead
We have started
Phase 2
Phase 2 evaluation of current services Community inpatient rehabilitation services will
be commissioned on a scalable basis to enable capacity to be flexed over time in response to changes in demand
Development of a community prevention and support model for people – with people supported to remain independent for as long as possible, and only using services only where necessary (BCF)
The CCG has restated a commitment to commission rehabilitation services from Frenchay and Thornbury, subject to plans being affordable and shown to be capable of delivering the required model of care
What is next?
The BCF Programme
3Rs Programme is a key element of the South Gloucestershire BCF Programme
This is a key national driver to promote integration between health, social care and voluntary sector services
There are 5 key Projects i.e.(1) Happy Healthy & At Home Cluster Model(2) The 3Rs Programme(3) Connecting Care(4) Dementia Friendly(5) Valuing & Enhancing our local care homes
How does this fit withthe BCF Programme?