1. Pathway to Placement Project
Lynne Haworth

2. Why did we initiate the project?
Historical position: Population with long term health conditions, housing stock, deprivation levels.
Context: higher than average numbers of adults admitted directly or from short term care into long term residential care, often following brief illness when previously independent.
Other factors e.g. culture.
Decision in 2015 to work with business partner to review current position.

3. Pathways review Hospital Short-term care Residential intermediate care
Reablement,
therapy or or
Long-term residential care
Own home (including extra care housing option) or

4. Process Set up multi-disciplinary working group
Analysed current pathways and available services
Introduced panel process
Tailored in-reach activity programmes
Weekly MDTs using whiteboards
New services to encourage home first
Data collation and analysis

5. Principles Asset based and preventative approach
Personalised support to go home and remain there
Carer and family support
Home first philosophy
Identified and re-established informal support
Longer term - integrated locality teams
Prior to working with Newtons Europe , short term care was seen as a virtually inevitable step to long term care – PEOPLE OFTEN WENT INTO LONG ERM CARE FROM HOSPITAL AND COMMUNITY AS FIRST RESPONSE
Changed approach to a recovery model – individualised and asset based, saw need for short term care as temporary
By introducing a focus on each individual - introduced whiteboards
Simple but very effective, no additional resources, refocussed social workers and managers to concentrate activities to move people through short term care as quickly as possible
Designed inreach reablement
Brought number of agencies together
Introduced panel scrutiny and short date approvals
Weekly improvement cycle meetings were introduced , attended by a range of agencies, and voluntary sector representatives , the meetings reviewed every individual in the Borough currently in short term residential care and ensured that all options were explored to facilitate the person returning home, including therapy, in-reach reablement, moving and handling assessments and voluntary support

6. Methodology

7. Impact on admission rates
17% reduction in long term admissions over a 12 month period.

8. .
Case study - Mrs R
Mrs R was admitted to hospital from her own home where she had been living downstairs, rarely leaving the house due to anxiety and reduced mobility.
She was discharged into a short term recovery bed where the reablement team, psychology and therapy colleagues collaborated in an ‘in-reach’ programme working with Mrs R and the care home staff to encourage her to mobilise, gain confidence and consider going home.
This was a process which took Mrs R through a journey from being non-weight-bearing and extremely anxious to being fully mobile and confident and ready to go home over a period of 6 months.
Mrs R’s case was discussed on a weekly basis at the whiteboard meeting, Mrs R was fully involved in all stages and the team went at her pace.
Mrs R now lives in an extra care facility with minimal formal support and has developed a network of informal relationships and arrangements which support her to maintain her independence.

9. Feedback from some of our service users

11. Conclusion Simple yet effective approach
Better understanding of the business
Culture shift in approach to short term care
- social workers/carers/acute trust/individuals
Workforce development opportunities identified
Sustained results
Ongoing
Short term can be long term!

12. Thank you lynne.haworth@blackburn.gov.uk