Gold Standard Care Pathway

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Gold Standard Care Pathway

• West Sussex ABI Network
• September 2007

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Gold Standard Care Pathway

• Joint Proposal by West Sussex ABI Net
• SABIF

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Gold Standard Care Pathway

• Acquired Brain Injury
• For the purposes of this care pathway and
  services currently provided by Sussex NHS and
  Adult Services, Acquired Brain Injury is an
  injury resulting from an accident (e.g. road
  traffic accident, assault) causing trauma to
  the brain, subarachnoid haemorrhage, viral
  infections such as encephalitis, meningitis, or
  anoxia (lack of oxygen). Although some strokes
  e.g. Subarachnoid Haemorrhage are classified as
  ABI, the vast majority of people with strokes
  would not be. Stroke has a separate care pathway
  and has appropriately developed services to meet
  need.

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Gold Standard Care Pathway

• We know the problems encountered by people with
  ABI
• Drawn upon good practice elsewhere in the country
• Informed by feedback from everyday working
• The views of service users and carers from Open
  Space (2004) and Headway

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Gold Standard Care Pathway

• Our Approach
• To recognise the long term nature of needs
• To construct a care pathway which reflects this
  rather than a diagram plotting a persons movement
  through a system.
• To be person centred
• Needs led

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Gold Standard Care Pathway

• A framework which describes options at any point
  of recovery
• From many years post injury to day one
• From long term care and support to acute care

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Gold Standard Care Pathway

• We want to redefine what we mean by a care
  pathway
• To focus upon needs, not services
• Long term rather than short term
• Individualised approach rather than one size fits
  all

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Gold Standard Care Pathway

• Values and principles
• Services should be person centred
• People should have as much control over their
  lives as possible
• Carers and families needs should be assessed and
  their views and needs taken into account

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Gold Standard Care Pathway

• Health and Social Services should commission
  and/or provide integrated services
• ABI should be recognised as a service category in
  its own right
• Data should be collated about the incidence of
  ABI nationally and locally

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Gold Standard Care Pathway

• Services should address long term needs
  including
• Health and Social Care
• Vocational training
• Education
• Employment

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Gold Standard Care Pathway

• Capacity
• Pivotal to addressing needs is the issue of
  Capacity
• This will require careful assessment and
  reassessment
• Take into account changes and improvements and
• The nature of the decision required

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Gold Standard Care Pathway

• Our approach should embrace both a medical and
  social model of disability
• Emphasis of moving away from medical to social
  model as time from injury passes
• Multi disciplinary approaches work best
• MD Teams working with a range of medical and
  social care skills most effective

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Gold Standard Care Pathway

• Person may need the support of both non
  specialist and specialist services
• Most cases can be dealt with by appropriate non
  specialist services
• Specialist advice and guidance should be
  available to support these when needed.
• Changes to what is currently available will be
  required

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Gold Standard Care Pathway

• Local Services will need to be able to meet long
  term neurological needs
• At present these are not provided everywhere
• People will need to be able to access and
  re-access services many times
• Services should not be time limited

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Gold Standard Care Pathway

• Equity of Services means
• High quality services everywhere
• Anti discriminatory practices and policies

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Gold Standard Care Pathway

• We propose a managed care pathway approach
• One that matches level of need to the right
  services
• Gives responsibility to managing the care pathway
  to the right people with the right skills

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Gold Standard Care Pathway

• Rather than describing the journey someone might
  take we should describe the options and how these
  can be accessed.
• To enable the timely transition at any point in
  the care pathway we propose a single point of
  access
• The SPA will be a MD team.

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Gold Standard Care Pathway

• The SPA will manage the care pathway at a county
  level
• It will draw from and manage the work of 2/3
  treatment teams for West and East Sx Brighton and
  Hove
• The SPA will act as a referral point
• Open referral system

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Gold Standard Care Pathway

• SPA will manage the journey of individuals
• It will use criteria to match needs to services
• 3 levels of services graded 1 to 3
• Level 3 requiring full case management for the
  most complex cases
• Level 1 requiring logging of data only
• All cases will be logged with the SPA

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Gold Standard Care Pathway

• The majority of cases (level 2)
• Advice and guidance on the management and care of
  patients
• To hospital, rehab units, community teams or
  people in other services
• This is specialist support to local non
  specialist services

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Gold Standard Care Pathway

• The 3 Treatment teams will be Multi disciplinary
• Health and Social Service professionals
• Jointly commissioned and managed
• Pooled budgets wherever possible

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Gold Standard Care Pathway

• Acquired Brain Injury Co-ordinator (2 currently
  in post for East Sussex Brighton and Hove and
  West Sussex)
• Clinical Neuropsychology
• Speech and Language Therapy
• Neuro Occupational Therapy
• Neuro Physiotherapy
• Social Worker
• Specialist Brain Injury Nurse (Specialist head
  injury nurse currently in post employed by BSUHT)
• Administrator

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Gold Standard Care Pathway

• Multi agency work will be necessary e.g. mental
  health cases
• Close working links will be developed with a
  variety of other agencies including

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Gold Standard Care Pathway

• Workability Job Centre Plus, Remploy
• Housing, aids and adaptations
• Headway/Association
• Disability Employment Advisers/Job Centres
• Citizens Advice Bureau and benefits advice
  workers
• Non Statutory Sector Organisations
• Information about Disability Access Programmes
• Carers Support Officers and/or a liaison with
  local support groups
• Advocacy groups

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Gold Standard Care Pathway

• SPA - Assessment/Referral Panel
• Social Services policy officers (county wide
  brief)
• ABI Co-ordinator
• Two- three therapists (representation from each
  team)
• Brain Injury Nurse

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Gold Standard Care Pathway

• Financial Benefits
• We believe there are large economic savings to be
  made by effective expert management of this
  complex group to both the NHS and Social
  Services, particularly those already placed in
  out of county specialist or non specialist units
  or inappropriate day care, homecare or mental
  health resources. (Reference Bromley, East Surrey
  and Northumberland services).

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Gold Standard Care Pathway

• Benefits to Service Users and their carers
• We believe these proposals will enable many
  people to gain a great deal more control over
  their lives and attain much more independence.
• The centralisation of specialist knowledge and
  skills will help inform future commissioning of
  services both at a local level and also from
  national providers both NHS and independent.

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Gold Standard Care Pathway

• These proposals support the implementation of the
  NSF for Long Term conditions
• We list a table of how each of the quality
  standards can be met using this approach

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Gold Standard Care Pathway

• Full text can be obtained from www.westsussexabi.c
  o.uk
• Consultation continuing, drafts being updated
• Your views are important!

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Gold Standard Care Pathway

• Send your views to
• abicoordinator_at_tiscali.co.uk
• Or via www.westsussexabi.co.uk