Medium term response -information for design workshop

What is a medium term response? Key points    This response is similar to that provided by existing community intermediate Care services who currently provide up to 6 weeks social care OR health rehabilitation and reablement as step up or step down support. The review indicated that in the future an integrated health and social care team would be better placed to meet both the health AND social care needs of people who require this type of response and reduce duplication. In the future this response will need to include; Therapists, nurses and social workers working with a joint team of health & social care re-ablement workers to deliver and review intermediate care support and care plans. Access to Geriatricians for advice and expert opinion– with the option of review by the Geriatrician, when a patient requires it. Better and more timely access to therapy skills and expertise. Falls assessment as an integral part of this service response. Length of this response should be based on need – so less than 6 weeks where appropriate and more if needed. Access to social prescribing services and workers skilled to assess and respond to low level mental health needs, loneliness and social isolation.

National guidance/ evidence base (medium term) The Department of Health’s guidance- Intermediate Care – Halfway Home (2009) suggests that; The emphasis of intermediate care should be on active enablement, which is likely to require any one of a range of therapeutic skills, including support for the social and environmental adjustments that users and their carers may need to make in response to reduced functional capacity. Inclusion should be based on individual need rather than diagnostic group. Using a shared assessment framework across agencies, professions and facilities is essential, This can help to avoid the person undergoing multiple assessments. The assessment should lead to an intermediate care plan for each individual, with a team member making sure that it is carried out and the individual and their carers as key participants in any decisions made. It should be planned as one multi-disciplinary and multi-agency service.   Re-ablement services help people to regain their independence after a crisis, and can have a significant positive impact on people’s quality of life. The recent study on the impacts of re-ablement, from the Personal Social Services Research Unit and the University of York, showed that those going through a re-ablement programme experienced a significant improvement in health-related quality of life compared to a comparison group. In addition, the report suggests that re-ablement is cost-effective for local authorities. For the 10 months after a re-ablement programme, people's care costs were around 60% lower than those who had not gone through a re-ablement programme - which significantly outweighed the initial costs of providing the reablement service to people. A vision for social care. 2010

National guidance/ evidence base (medium term) A systematic overview of economic evaluations of health related rehabilitation published in the Disability and Health Journal (Sept 2015) demonstrated that “cost effectiveness evidence supports the view that health related rehabilitation services should have similar priority to conventional medical treatments in health care systems.” For example it can; Reduce the cost of nursing, residential and social care Reduce the risk of falls Reduce length of stay costs Help people retain and regain independence and maintain productive roles. Commissioning guidance for rehabilitation NHS England 2016 The public health guidance older people- independence and well being (5) published by NICE in Dec 2015 recommends that all staff in contact with older people should be able to identify those most at risk of a decline in their mental wellbeing. This includes being aware that certain life events or circumstances are more likely to increase the risk of decline. Most people who use intermediate care services will have one or more of these risk factors, therefore links between IC services, Social Prescribing services and community and voluntary sector are crucial.

Examples of good practice Who else is doing it? Examples of good practice Kent Integrated Reablement Team – Pioneer site providing holistic care to improve management of long-term conditions, confidence/self-management, supported by a multi-disciplinary team (MDT) http://www.local.gov.uk/documents/10180/6927502/Kent+Pioneer+Programme/4eca7d25-5571-4925-b1   Greenwich Community Health Services Reablement – coordinated health & social care teams using one pathway to enable people to maximise their independence. http:// www.greenwichccg.nhs.uk%2FNews-Publications%2FDocuments%2Fintegrating_health_and_social_care.doc&usg=AFQjCNFQgkSUlsKfcyhmlxnrYs_okJOUSg The Salford Integrated Care Programme designed to improve care in 3 ways: Self management, integrated MDT, single point of contact, to provide support to manage long-term conditions & better navigate the health and social care system http://www.nets.nihr.ac.uk/projects/hsdr/1213033

Who needed a medium term response? Four groups of people may need this response; 1. People leaving hospital/ bed based service who need home based reablement or rehabilitation- referred directly by the ward or bed based service. 2. People in the community who need reablement or rehabilitation to avoid an admission. 3. People who are having planned surgery -who could be referred as part of their pre op planning. 4. People who have received a crisis response or intensive support from the intermediate care service and who now need a less intensive service.

Who needed just an medium term response (1, 2 and 3)? Age- People who needed this type of response were slightly younger than other responses. 39% were under 80 and only 16% over 90. Home situation- 59% lived alone prior to the episode reviewed and over three quarters without any type of formal care package or support. Long term conditions (LTCs) - 70% required regular monitoring of their LTCs (10% more than the other home based responses). 8% of those who needed monitoring also needed regular interventions linked to their LTCs. 42% had heart problems, 19% had Diabetes. A quarter had a pre-existing respiratory condition and for 16% breathing problems were affecting their mobility at the point of referral. More likely to have arthritis than other responses (24%) Dementia/ Cognitive Impairment- 12% had an existing diagnosis of Dementia and 4% were known to have Cognitive Impairment prior to this episode. However the level of need around cognition and memory was lower than other responses. (14% had medium need, only 3% had high) Mental Health- Low level mental health issues including low mood, lack of confidence and anxiety were present for 29% of this group. Mobility-More independent with mobility and transfers prior to this episode than the other responses, but reduced mobility and difficulties transferring were the main needs when they were refereed to intermediate care. Falls- 66% were are a falls risk and for 24% falls was the reason for this episode of care. Just under half of these had sustained a fracture as a result of the fall (10%) and many of these had then required unplanned surgery. Planned surgery- Around a third of those who needed this type of response were admitted for planned surgery and required some form of rehabilitation, reablement or temporary support at home following this. Wound care- 30% had a wound, requiring a simple dressing; this was usually as a result of surgery. Activities of daily living- The majority of people who required this response needed some support with personal care and domestic activities of daily living but this at a lower level than the other responses.

What types of interventions were needed? (medium term response)

What types of interventions were needed? (medium term) Medical investigations/ tests included… Blood tests Investigate cause of falls or dizziness. Bone health review Continence Psychiatry/ mental health review Continence review Repeat scans. Cardiology follow up. Clinical interventions identified were… Wound care (incl surgical, pressure areas) Catheter care and nutrition. Cellulitis management COPD management Blood sugar monitoring Long term conditions management Monitor fluids/ nutrition Pain management Deltaparin Other types of interventions… Education/ self care advice Fire Safety assessment Refer for major adaptations Joint work with addiction services Arrange NOMAD/ assess self medication skills Review of personal budget arrangements Housing advice/ support Best Interests meetings End of Life care Reablement included… Supported ADL practice Practice mobility, stairs, transfers and using equipment. Prompting (to take meds, eat, maintain hip precautions, do exercises etc) Assess need for ongoing support. Strategies to compensate for memory/ cognitive problems. Exercise programme Breathing exercises Provide equipment. Maximise function Gradually reduce as recovers/ improves/ adapts to… Rehabilitation included… Rehab post surgery or post fracture Physio review OT assessment Specialist neuro or stroke rehab Continue rehab programme from hospital.

Who is needed to deliver them? Most frequently identified Occasionally identified Reablement Reablement workers with therapy plan Reablement workers Reablement workers with MH plan Homecare/ reablement workers Regular clinical intervention Nurses Specialist nurses Wellbeing / Social Prescribing CVS Social care/ CVS ---------------- Mental health/ CVS Falls Programme/ Falls Advice As determined by assessment Therapists MDT Geriatricians Carers Support for informal Carers CVS/ social care Dementia Navigatior Nurse/ Therapist Rehabilitation Physio Specialist therapy (neuro/ stroke) SALT Assessment for home care Reablement/ social care Social care -------------------- --------------- Telecare Medical investigations /tests GP ------------- Specialist teams Medical /Clinical review Orthopaedics/ fracture clinic Urology or other specialist Ongoing Home Care package Home care provider- private or social care funded. Cognitive Assessment GP/ OPMH OPMH Geriatrician Neuro assessment Psychological Support /Counselling Mental health services IAPT Specialist service Joint Care Planning With mental health With alcohol/ addictions service With partner of family members care team With specialist team Medication Review /Advice Mental Health Pharmacy ----------------- Comprehensive Geriatric Assessment Telehealth Specialist Nurses -------------------

What patients told us…