Reablement Seminar New Connaught Rooms London 24 January 2008

December 2007 Lynne Brown London Borough of Sutton Start S hort T erm A ssessment & R e-ablement T eam

December 2007 Lynne Brown London Borough of Sutton History Complex/ Intensive Extra Care START (short term assessment and reablement team) Nature of work Supporting intensive and complex packages only: 86% of hours delivered within 10+ (intensive) packages plus some complex C&F, LD and MH work On site team based in extra care buildings provide flexible care within an agreed ceiling of hours per service user. Primarily supports hospital discharge. Shared capacity with Health Intermediate Care Team. Direct access to nursing and therapy services.

December 2007 Lynne Brown London Borough of Sutton Research

December 2007 Lynne Brown London Borough of Sutton As Is Community Equipment Changes OT Queries Issues etc Community Equipment Changes OT Queries Issues etc CM review START Provider Care Manager ICP STARTBrokerageICP District CM Changes Voluntary Sector/Other Close CM review Provider Brokerage Referral Types Hospital Discharge Duty Comprehensive Standard Short None (Draft 6 only) Assessment Types Risk Assessment Moving & Handling Assessment MAINSTREAM SWLEOC Risk Assessment M&H Risk Assessment Ability/ADL Assessment Medication Access ICES Preventative Services Physiotherapy/OT Progress on Paris Care Manager Assessment Types Risk Assessment Moving & Handling Assessment Referral

December 2007 Lynne Brown London Borough of Sutton To Be Risk Assessment M&H RA Medication Access ICES Preventative Services Physiotherapy OT Progress on Paris Changes START Trusted Assessor Outcome focussed CarePlan Maintain CarePlan & Safe Working practices Changes District Duty Desk CM reviewBrokerage Care Manager ICP SWLEOC OT/Physio GP/Community Matron Provider Duty Assessment Format

December 2007 Lynne Brown London Borough of Sutton Service Model Our intention is to provide a service which: –Is a universal reablement service open to all –Works closely with service users and carers to maximise independence –Assists service users to link in with other support services –Takes referrals from both health and social services –Refers directly to specialist health care practitioners where required –Is a flexible service, which can respond quickly according to need and can accept referrals outside of traditional hours –Where ongoing care needs are identified, reviews and hands over individualised outcome focussed care plans, which will be maintained by mainstream providers

December 2007 Lynne Brown London Borough of Sutton Focus Intake of all new homecare referrals to promote independence from first contact with services Support of timely hospital discharges Prevention of admission to hospital Prevention of admission to residential or nursing care Prevention of breakdown / provision of crisis support to informal carers Detailed assessment of complex cases – for instances where there is uncertainty about risk management

December 2007 Lynne Brown London Borough of Sutton Benefits Service Users –Promote maximum independence and well being –Reduce number of hand-offs –Reduce the cost of life long care Care Management –One point of referral/streamlined process –Reduce duplication –Allows time for dedicated social work External Providers –Care delivery issues sorted out before hand over –Hand over in all cases –Standardised documentation

December 2007 Lynne Brown London Borough of Sutton Next Steps Business Tracking Processes Consultation Workforce development in the outside market Developing commissioning