Right Therapist, Right Time : Collaboration and Partnership

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Right Therapist, Right Time Collaboration and
Partnership

• Barbara Stoker
• Clinical Director Integrated Therapies

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Integrated Partnership
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2013..
Change
Maintaining partnership stability
Protect
Prevent
Defend
Reduce Impact
Clinical skills expert
knowledge planning Integrated working
training
Essential
Core competencies service delivery

Future
Proofing
?Future markets ?Future
funding ?Future proof
resources
Uncertainty
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Strengths

• Proactive
• Person Centred
• Skilled staff and resources
• Consistent approach across the service
• Recruitment of high calibre staff
• Flexible workforce
• Partnership Board

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Attitude is a little thing that makes a big
difference.

(Winston Churchill)
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Service Improvement
Maintaining Partnership stability
Protect Prevent
Defend
Reduce Impact
Clinical skills expert knowledge
Planning Integrated working
training
Core competencies service delivery
Staff Development
Future
Proofing
Essential
Future
markets Future funding Future
proof resources
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Common Aims

• Prevent avoidable hospital admissions
• Prevent admission to care home
• Reduce length of stay
• Reduce social care waiting lists
• Take care (therapy) closer to home Rehab

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Oscar Wilde said.

• So it was time to make some noise!

There is only one thing in life worse
than being talked about, and
that is not being talked about.
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Shaping Future Services

• Capacity and demand in community services
• Sampling/walkabout/newreview/levels of rehab
• Identify gaps and consider the impact
• Tolerate and wait
• Moniter and collect data
• Measure the impact and report (service plan)
• Where is the money to support development/change?
  
• Information data
• Everyone needs a Jayne (performance pictures)
• Representation at all levels
• Targeted groups/meetings/people hard soft
  sell
• The right currency to use what do you count?

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Prevent avoidable hospital admissions AE
Therapy

• Funding SHA ?CCG winter ?BCF
• Supporting metrics
• Referred - Response time
• Discharged - Discharge destination
• Assessment Level - Outcome
• Follow up - Patient story samples
• Age - Activity sample weeks
• Reports completed to increase capacity
• 8am 8pm 7 days
• Supports AE/AAUs
• Direct access to Rapid Response/PCH
  beds/Intermediate Care/Reablement/Community Rehab

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Prevent avoidable hospital admissionsRapid
Response Therapy

• Commissioned by CCG but funded with nursing
• Limited funding for therapy 7 day service
• Staff consultation 7 day community
• 7 day with 5 day funding
• 8 am 8pm
• Now permanent (STees CCG)
• Rapid Response equipment package training
  provided to nursing and sub store access to
  prevent hand off
• Referrals via central point

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Prevent admission to care home Reablement

• Middlesbrough

• Redcar Cleveland

• Reablement provided in house to follow up
  discharge from Intermediate care and provide
  specialist reablement
• Direct access to community rehab
• Out sourced Human Support Group.
• Provides OT support workers
• Integrated Therapy provides training
• Operational group chaired by social care OT

• Rablement in house. Therapy provided by
  Integrated Therapies
• Redcar Reablement Unit 7 day therapy seconded.
  Activity Therapy directed. Pilot extended further
  18 mths
• Direct access to community rehab

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Reduce Length of Stay

• Middlesbrough

• Redcar Cleveland

• Reablement
• Time2Think
• Yr 1 health commissioned local care home with
  Integrated Therapies
• Yr 2 social care commissioned alternative
  provider
• Yr 3 health commissioned local care home with
  Integrated Therapies
• 6 beds dementia 14 assessment/recovery beds
• Access via Single Point of Referral

• Rablement
• Discharge Decision not made.
• Assessment/recovery beds commissioned by social
  care from care homes
• Integrated Therapies via Reablement with direct
  access to community rehab

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Reduce Length of Stay Early Supported Discharge
(ESD) Stroke

• Stroke pathway commissioned by Stees CCG via
  IMProVE programme
• Closure of 2x community bed bases reducing beds
  from 18 to 12
• Staff consultation to provide 7 day stroke rehab
  within PCH and ESD. Recruitment to ESD
• Completed within 12 weeks
• Completes pathway from acute community to social
  care
• Collaboration with social care reablement to
  provide on going support
• Pushed the rehab debate for trauma, neuro and
  complex cases

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Reduce social care waiting times

• Impact on social care of treating people at home
  is often overlooked, e.g.specialist equipment,
  housing adaptation
• Increasing demand v fluctuating capacity
• New computer system
• Increase in complex cases
• Adapted social work complexity tool to provide
  common understanding
• Monitor caseloads through regular snap shot
  caseload analysis
• Performance report through Partnership Board
• Care Act
• Increase in staff resource (non recurrent
  funding)

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Skills sharing

• Equipment
• Self assessment of competency
• Levels of training provided
• Themed packages
• Equipment prescribing - widening permission
• Nurses/Social Workers/OTs/Physios/Support staff
• Next
• Respiratory
• Dementia
• Stroke
• MSK

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Top Tips

• Building a set of metrics that support the
  messages and if you havent got one find a Jayne
• Invest / nurture project leadership
• Annual service plan Staff/Service
  Delivery/Quality/Development
• Use representation at every level
• Look for the gap and make a business case for
  this regardless of who will provide as the right
  service in place benefits everyone
• Build skills into the workforce which reflect the
  make up of your area.
• Pathways should lead on to networks of support to
  prevent relapse, social isolation and ensure
  community reintegration

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For the patient/customer

• Services funded separately but these are
  connecting up across STees health and social care
• Whole system to meet need and provide choice
• There are still gaps most notably in community
  rehab but through the CCG IMProVe programme
  there is to be significant investment in
  community therapy to provide rehab close to home.
  This will include 7 day PCH, rehab coordination,
  single point of access, higher level of rehab in
  a persons own home

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Its all happening.

• The right time is now!