future vision of rehabilitation services what do we need to do to meet the challenge? ...
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Future Vision of Rehabilitation
Services What do we need to do to
meet the challenge?www.rehabilitationframework.scot.nhs.uk
A Delivery Framework ForAdult Rehabilitation
Key messages Integrated working across
professions and agencies Innovative approach to service
delivery Focus when re-designing services
on patient journey Measure the impact
Links with other Scottish Government work streams
Better Health, better Care Changing lives Review of Nursing in the
Community An employability
framework for Scotland Shifting the balance of
care Joint Futures / Joint
Improvement Team – Intermediate Care
HEAT targets SPARRA
Community Hospital Strategy
CHP Toolkit Mental health delivery plan National Strategy for LTC’s Supporting self care Better outcomes older
people + national strategy Health inequalities task
force 18 week targets National outcomes
framework for community care
Patient Experience Programme
Challenges for Framework implementation Move away from a reactive, unplanned and
episodic approach to rehabilitation Re-design of services to ensure this can be
achieved True integration of community
rehabilitation teams and local authority teams
Provision of earlier interventions for those individuals going onto sickness benefit
Develop case / care management approaches within integrated rehabilitation services
Key Requirements Co-ordinated and Integrated
Service user focused Single point of access into rehabilitation
services Shared documentation Integrated social and health care teams
delivering prevention, self management and enablement – reducing transitions of care
Case / Care management approaches
Key Requirements –Co-ordinated and Integrated
Fundamental shift in how and where we deliver services – focus needs to be on prevention, self management, early intervention and enablement
Recognising, harnessing and developing skills of health and social care practitioners
Utilising and developing technologies to underpin new services
Improving the evidence base around rehabilitation services
Measuring the impact
28/10/06
Older People’s Services
a better life for older people in Scotland, now and in the future
supporting older people to live healthy independent lives
supporting active ageing and promoting positive attitudes towards ageing
valuing older people and supporting them in continuing to contribute to Scottish society
HDL – Falls for CHP’s NHS Boards need to have a combined falls
and bone health strategy which CHP will implement
CHPs need to appoint a falls prevention lead or coordinator to work along side the rehab coordinators
CHPs need to develop an operational falls prevention and bone health implementation strategy targeted at those for whom there is evidence that effective intervention will reduce the risk of future fractures and falls.
Protocols are in place to ensure falls risk minimisation; A systematic process is in place for the management
and prevention of falls; Appropriate falls awareness education, support and
guidance is provided to all staff, regardless of their role in the hospital, where patients may be at risk of falling;
Accurate recording and reporting of incidents, including falls, are reported through the incident reporting procedure; and
HDL – For Hospital Settings
Progress to date!
National ImplementationGroup
Representation from: Patient rep, SWIA, Changing lives team, health, housing, AHP, SSA team, Scottish Govt reps, Community Planning Partnerships
Remit – advisory, a forum to support shared learning and emerging good practice, monitoring the impact of implementing the recommendations
4 meetings to date. Updates published on www.rehabilitationframework.scot.nhs.uk
National Implementation Plan 5 High Impact Changes – with
improvement actions and time scales and explicit links with:
HEAT targets Community Care Outcomes National Performance Framework;
National Outcomes Single Outcome Agreement
Opportunities for health promotion, self management, on-going rehabilitation and maintenance are maximised, using for example community centres and other leisure facilities. These facilities are readily accessible by local transport
1. enhance opportunities for the population to keep fit and active. Recognising the health gain and social engagement benefits of using mainstream leisure facilities for health promotion and rehabilitation
2. build on existing good partnership, working with the voluntary sector to develop accessible information for users and carers and professionals on self management support and rehabilitation services available in local areas.
3. work in partnership to facilitate the development of suitable local transport for rehabilitation purposes.
Falls – supported active aging – minimising the risk of falls and low trauma fractures – accessing appropriate services
Health and Care Pathways provide single point of access for rehabilitation services. This will be supported by appropriate tools for screening, triage and assessment and information on availability of services with a focus on improving service user experience.
enhance access to services, information and sources of support for individuals requiring uni-professional and multi-professional rehabilitation, including:
developing a single point of access to services. introducing direct access to services Utilising NHS 24 as a resource for information, advice, triage
and access to rehabilitation Access for individuals living in care homes Utilising the Comprehensive Geriatric Assessment (CGA) for
older people whether in the community or in acute hospitals Utilising the SSAFalls – early identification, ambulance, NHS24, A+E, in-
pt services, dexa services, community alarms
Older people and people with long term conditions are supported to live in their local communities with the appropriate integrated rehabilitation / enablement services.
integrated approach to rehabilitation / enablement services can be developed to meet the needs of the growing number of older people, people with long-term conditions and those with specialist rehabilitation needs.
identify how anticipatory care and rehabilitation services can be focussed on “at risk” / vulnerable individuals to provide early intervention, prevent unnecessary admissions to hospital or care facilities and facilitate smooth transitions from hospital or specialist services
linking together early intervention/rapid response services with community rehabilitation teams, specialist rehabilitation and nurse/therapist led units, community hospitals and integrated care to provide seamless transitions of care.
NHS Quality Improvement ScotlandFalls Programme (Dec 2007-Dec 2009)
Falls Community of Practice CH(C)P Falls Leads sub-group Online Falls Community
www.fallscommunity.scot.nhs.uk New resource: Up and About:
Pathways for the prevention and management of falls and fragility fractures (available in electronic format Summer 2009)
Falls community of practicewww.fallscommunity.scot.nhs.uk
Exchange knowledge, ideas, experience and good practice
Find useful resources
Access pre-programmed searches
Find and contact colleagues
Discuss topics of interest
NHS Quality Improvement ScotlandFalls Programme (Dec 2007-Dec 2009)
The development of data standards for falls, in partnership with the National Dataset Development Programme, ISD
Promoting a consistent approach to the development of falls training programmes for health and social care staff in Scotland, in partnership with NHS Education for Scotland
The development of : an fact sheet to assist services in identifying older people at
high risk of falling in the community (September 2009), and recommendations for the use of clinical outcome measures in
the management of older people who have fallen (consensus development meeting September 2009).
Care Commission – Inspection 2009/10 Inspection Focus Area on ‘Meaningful
Activity’ the Care Commission is supporting the priorities outlined in the Health Department Letter (HDL) (2007) 13, issued in February 2007.
Supported by appointment of Rehabilitation Consultant within Care Commission
The Care Commission aims to ensure providers are: Aware of the Scottish Government
policy and strategic direction Regularly carrying out falls risk
assessments Taking action to minimise the risk of
falls and the consequence of falls, including fracture
Aware of the contribution of other professionals, services and agencies
NHS 24 – PhysiotherapyTriage
Single point of access into PT. Improving access to services (especially for remote and rural areas)
Reduce waiting times Improve patient
experience and patient safety
providing cost efficiencies
introducing new and different roles for AHP professionals.
MSD Website Development
review the contents of the Working Backs Scotland website
explore the development of an additional website relating to Upper Limb and Neck conditions
investigate if these websites could form part of a suite of MSD sites including the existing ‘NHS Lothian knee website’
Useful web adresses www.rehabilitationframework.scot.nhs.u
k www.enablinghealth.scot.nhs.uk www.fallscommunity.scot.nhs.uk www.ltcscotland.wiki.is