South Gloucestershire Rehabilitation, Reablement

& Recovery Programme

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

The Model

INPUT/OUTPUT

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?

INTEGRATED CARE SYSTEM

The BCF Programme

ANY QUESTIONS?