1. Gloucestershire County Council & NHS Gloucestershire Clinical Commissioning Group Carer Rights Day Event: Friday 28 th November 2014 Robert Walker, Head of Reablement Delivery & Transformation

2. Workshop Objectives: To outline GCS hospital discharge processes and the involvement of patients family/carers To inform participants of the GCS locality structure for Adult Community Health & Social Care Integrated Community Teams (ICT’s) To inform participants of the planned re-design of Reablement Services within the ICT’s To discuss how a Person Centered and Carer Centered approach is achieved within the Hospital Discharge and Reablement Pathways

3. Principles for all Community Service Staff to follow when discharging patients GCS is committed to ensuring that effective discharge and transfer takes place for all of its patients Discharge should be well organised, safe and timely involving smooth transfers to a range of Health and Social Care Services Each patient will be encouraged and supported in self-care activities and aided to achieve the highest possible level of independence Patient and carers and family are prepared, physically and psychologically for discharge from caseload, transfer home or to an agreed alternative environment

4. There is effective and timely involvement, communication of relevant information regarding discharge and transfer plans to patients their families and/or carers and that families and/or carers are supported and assisted throughout the process There is continuity of care between the hospital and the agreed discharge care environment, with seamless service transition The discharge and transfer process is a multidisciplinary, interagency process during which the needs and resources of patients and carers and families are assessed This process must involve the patient and carer who should be placed at the centre of any decision making and kept informed at all stages of the process

5. Discharge Planning - Relatives and/or Carers: Most patients want their relatives and carers to be involved in their discharge planning but some patients consider this a breach of their privacy. Other patients are happy for some relatives/carers to be involved but not others. It is essential that, before any information about a patient is shared, staff check and document the patient’s wishes. If the patient lacks capacity, a best interests decision should be made, following the Mental Capacity Assessment (MCA) policy Provided there is patient consent, it is vital that both relatives and carers are engaged as soon as is appropriate following hospital admission in the discharge planning process. They should be asked to:

6. Provide information to staff about current issues / needs of the patient or themselves, which should be documented on the Multidisciplinary Discharge Planning Form Actively participate, as appropriate, in care and discharge planning. The identified relative and carer must be: Informed of the person responsible for co-ordinating care Be provided with contact details of their Social Worker / Care Assessor / Community Nursing team where applicable Be informed of expected length of stay, and estimated discharge date(s) Be made aware of how to access a carers assessment www.carers.gov.uk www.carers.gov.uk

7. Locality Structure Director of Adult Services Cheltenham & Cotswold Locality Locality Manager Cheltenham & Cotswold Locality Locality Manager Gloucester & Stroud Locality Locality Manager Gloucester & Stroud Locality Locality Manager Tewksbury & Forest of Dean Locality Locality Manager Tewksbury & Forest of Dean Locality Locality Manager Tewksbury Business Unit Community Manager Tewksbury Business Unit Community Manager Forest of Dean Business Unit Community Manager Forest of Dean Business Unit Community Manager Gloucester Business Unit Community Manager Stroud Business Unit Community Manager Stroud Business Unit Community Manager Cheltenham Business Unit Community Manager Cheltenham Business Unit Community Manager Cotswold Business Unit Community Manager Cotswold Business Unit Community Manager Integrated Community Teams x3 Integrated Community Teams x4 Integrated Community Teams x3 Integrated Community Teams x4 Integrated Community Teams x3 Countywide Services Locality Manager Countywide Services Locality Manager Tele care

9. Definition of Reablement An approach or philosophy which aims to help people ‘do things for themselves’ rather than ‘having things done for them’ (Department of Health – Care Services Efficiency Delivery) Reablement is designed to support people to live at home safely, independently, meaningfully and in the way that they choose, enabling them to live their life their way. To help people to connect with and build sustainable family and local support networks that enables them to remain safe and supported by their local community, family, friends and neighbours. The restoration of optimal levels of physical, psychological, emotional and social ability in accordance with the needs and desires of the individual through the use of timely and focused intensive/time limited intervention which results in reduced on-going need for services.

10. Health Care Social Care

11. Reablement Provide customer focused outcomes Identify the Reablement pathway Ensure that Reablement pathways include emotional, psychological, social and functional customer focused goals Design consistent worker rotas across the County to ensure that capacity is used effectively and efficiently with the Integrated Community Teams within as a whole system approach

12. Pathway options Recovery (Initial Recovery and intervention) RehabilitationSocial Reablement Purpose: To enable timely hospital discharge/unnecessary admission for a period of recovery from illness/symptom exacerbation. To provide a period of intensive intervention and assessment to ensure safety at home and consider ongoing delivery pathways. Following a period of recovery/assessment, where this was necessary, to provide a period of rehabilitation from Physiotherapy and/or Occupational Therapy ICT staff. Ongoing personal and domestic care needs may be supported by independent care providers To provide person centred social Reablement supporting people to set individualised goals that will enable them to be in control of how they are enabled to live as independently as possible within their own community. Getting to know the person in relation to their past, present and future aspirations Agree person centred goals that matter to the individual that will help them to live their life their way and plans to achieve their goals. To help people to re-engage, access and build sustainable local support networks. Duration: Up to 4 days Duration according to individual need and progress up to 6 weeks. Duration up to 2 weeks

13. Pathway options Recovery (Initial Recovery and intervention) RehabilitationSocial Reablement Referrals Accepted From: SPCA Community Hospital Health & Social Care Staff IDT CSOs GPs Referral Route: Initial request will be directed to the ICT referral centres using a BICA for screening & triage. Initial request will be directed to the ICT referral centres using a BICA for screening & triage. Referrals from a registered Physiotherapist and/or Occupational Therapist following assessment of an individual’s Rehabilitation needs. Initial request will be directed to the ICT referral centres using a BICA for screening & triage.

14. Pathway options Recovery (Initial Recovery and intervention) RehabilitationSocial Reablement BICA Information Required: Reason for hospital admission/Rapid Response intervention Details of needs on leaving hospital What would the person like to be able to achieve? What could they achieve prior to hospital admission/Rapid Response? Has the individual got a current package of care in place? – If yes- frequency? Are there any Mental Health or cognitive concerns Yes/No if yes please state. Pen portrait of the person (to include previous activities, social abilities, life-style preferences). Assessment Process Core FACE assessment Tele Care assessment Moving and handling assessment including equipment provision FAB assessment Risk assessment Identification of ongoing pathway needs. OT/PT assessment Goal plan RWs to work alongside therapists Regular goal planning session Social Reablement to be delivered simultaneously Social care assessment Community networks explored Person centred plan to be developed including a minimum of three goals Sustainable community support network to be developed

15. Reablement Implementation & Delivery Flowchart Referral Sources SPCA / Acute Hospital Integrated Discharge Team Rapid Response CSOs Community Hospital Integrated Community Team Referral Centre MDT Triage Screening and Allocation Three Pathways Recovery Rehabilitation Social Reablement Four DaysUp to Six Weeks Two Weeks Criteria:

16. Reablement Pathways are designed to promote wellbeing ‘Wellbeing’ is a broad concept, and it is described as relating to the following areas in particular: Personal dignity (including treatment of the individual with respect) Physical and mental health and emotional wellbeing Protection from abuse and neglect Control by the individual over day-to-day life (including over care and support provided and the way it is provided) Participation in work, education, training or recreation Social and economic wellbeing

17. Domestic, family and personal relationships Suitability of living accommodation The individual’s contribution to society The importance of achieving a balance between the individual’s wellbeing and that of any friends or relatives who are involved in caring for the individual. People should be considered in the context of their families and support networks, not just as isolated individuals with needs. Account should be taken of the impact of an individual’s need on those who support them, and take steps to help others access information or support Independent living is a core part of the wellbeing principle