South Gloucestershire Rehabilitation, Reablement & Recovery Programme

What is the 3Rs Programme? Aim – To redesign rehabilitation, reablement and recovery services in South Gloucestershire to create a pathway which is focussed on: The understood needs of people Safe, high quality care that reflects good practice and makes the best use of scarce resource Equity and consistency Transparency for patients

Objectives Objectives More rehabilitation is undertaken in the community Patients will have improved continuity of care Reduce the time patients spend in an acute hospital setting Reduced need for long term residential care Improved outcomes for people

The Model

INPUT/OUTPUT

What will success look like? Success Criteria What will success look like? People: Will know what to expect and will be able to recognise and describe their needs, now and in the future Able to take informed risk about their own care. Will get support 24/7 Will be empowered and listened to

What will success look like? Success Criteria What will success look like? Carers: Able to refer to one plan of care that is person-centred; that provides continuity of care; and that recognises the needs of the carer Feel less burdened, marginalised and ignored Feel more comfortable with their responsibilities Get useful advice and information Have access to carer support Feel valued, recognised and heard

What will success look like? Success Criteria What will success look like? Staff: Social care and healthcare professionals have access to: Coordinated and managed services. ‘Wrap around’ services, covering all conditions. Specialist services Feel that people have been able to make informed choices Have access to a shared, trustworthy, electronic person database Know what is achievable and what is not Work in a culture that supports partnership, rather than paternalism

What will success look like? Success Criteria What will success look like? Acute & Community Services: Recognise clear, understandable, individually-funded pathways for the whole person journey, including agreed outcomes with clear rewards and penalties Can move care to the community with confidence – can ‘push’ while community ‘pulls’ Fewer unnecessary admissions, less extended LOS – better and more reliable ‘flow’ across the system Consultants are more willing and more confident to reach out into the community Have access to a shared, trustworthy, electronic person database Community Services will take care over from acutes, with confidence, once people are clinically, physically, mentally and emotionally stable enough

Continuous assessment and improvement Self-management The Person Centred Rehabilitation Lens Sustainability Carer views Acute / community in-patient rehab plan Complex home rehab plan Innovation Monitoring Personal First single POC Joint, collaborative assessment of need, options, choices, outcomes, incentives, management Managed conclusion of formal rehabilitation care and support The person, their carer and family in their community Rehab Plan Technology Feedback Continuous assessment and improvement Home rehab plan Incentives Education Re-assessment

Implementation Governance There are two broad phases to this programme: Phase 1: Describes current work to move towards the new model of care using opportunities as they arise to reshape services. This provides an opportunity to test and learn through evaluation of these projects Phase 2: This is the main phase for implementing the 3Rs model and includes the commissioning of long term arrangements for community rehabilitation services at Thornbury and Frenchay respectively

Phase 1 We have started There are many things that are already in development as part of Phase 1: Developing a new model of community services centred around local clusters of GP practices Improving flow through acute hospital through developing a single assessment process for patients and case managers to help navigate patients through the system Commissioning community rehabilitation beds in nursing and residential homes, and associated support Developing a new approach to reablement, focusing on supporting individuals to remain as independent as possible Refining the provision of sub acute rehabilitation at Henderson Ward, Thornbury and Elgar House, Southmead

What is next? Phase 2 Phase 2 evaluation of current services Community inpatient rehabilitation services will be commissioned on a scalable basis to enable capacity to be flexed over time in response to changes in demand Development of a community prevention and support model for people – with people supported to remain independent for as long as possible, and only using services only where necessary (BCF) The CCG has restated a commitment to commission rehabilitation services from Frenchay and Thornbury, subject to plans being affordable and shown to be capable of delivering the required model of care

The BCF Programme How does this fit with the BCF Programme? 3Rs Programme is a key element of the South Gloucestershire BCF Programme This is a key national driver to promote integration between health, social care and voluntary sector services There are 5 key Projects i.e. Happy Healthy & At Home Cluster Model The 3Rs Programme Connecting Care Dementia Friendly Valuing & Enhancing our local care homes

INTEGRATED CARE SYSTEM

The BCF Programme ANY QUESTIONS?