1. South Gloucestershire Rehabilitation, Reablement & Recovery Programme

2. 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

3. 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

4. The Model

5. INPUT/OUTPUT

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. INTEGRATED CARE SYSTEM

16. The BCF Programme
ANY QUESTIONS?