1. Community Rehab Team Kate Bradfield (Physiotherapist) Sarah McFarlane (Occupational therapist)

2. Team Purpose To optimise a patient’s mobility and independence with their activities of daily living by providing a specialist short-term rehabilitation service to patients in bedded units or in their own homes

3. CRISIS Consists of: Bed based Intermediate Care Intermediate Care at Home – High Priority - Medium priority CPAT (Community Prevention of Admission Team) Currently based at The Wilson, Mitcham Accept adults with a Merton GP Age > 18 years old Bed based units >55 years old

4. Community Rehab Team Supported Discharges and POA’s Bed-based Rehabilitation Units (24 beds in total) Home-based rehabilitation (up to three calls a day 8am- 6pm). Woodlands House (17beds) Carter House (7 beds) Colliers WoodRaynes Park

5. Referral Sources GP’s (via CPAT) Hospital Therapists Discharge co-ordinators Community Liaison Nurses CPAT Do not accept self referrals

6. Types of referrals Supported discharges From Acute Trust Referrals screened by a therapist and then placed on waiting list Prevention of Admission (POA) Referred by CPAT via direct referral from GP (telephone) or Rapid Response or STAR team Take priority over SD referrals

7. Conditions not accepted Patients presenting with symptoms primarily due to neurological diagnoses Need to be referred to:  The Community Neuro Therapy Team  The unidisciplinary Neuro Physiotherapy Team  New strokes to the Early Supported Discharge Team Patients with respiratory diagnoses who require only chest physiotherapy Need to be referred to:  The Community Respiratory Therapy Team

8. Who is appropriate? o Must have potential to transfer with carers/ therapy staff without use of a hoist, but could be with Molift / Re-turn / Rotastand/ Sara Stedy o Discharge destination must be known at time of referral for bed based o Must be medically fit for rehab o Must have rehab potential

9. Bed-Based Therapy Occupational Therapists, Physiotherapists & Rehabilitation Assistants Nurses and Carers Monday-Friday and RA weekend cover when capacity allows Length of stay dependant on therapists’ assessment and goal achievement – usually 2-4 weeks Weekly MDT meetings with temporary GP & nursing staff

10. Home Based Rehab (high board) Must have both Occupational Therapy (OT) and Physiotherapy (PT) goals Assessed by therapist on day of discharge if home by lunchtime. 1-3 therapy visits daily by a rehabilitation assistant Regular reviews by Occupational Therapist and Physiotherapist Increase independence in personal care, meal prep, transfers, mobility, stairs within patients own home.

11. Home Based Rehab (medium board) Require multidisciplinary input from OT &PT Can be supported with up to 2 - 3 calls in a week Contact within 3 working days of discharge from hospital to prioritize Increase and progress mobility, outdoor mobility, public transport and accessing the community.

12. Patient journey Mrs H is a 78 year old female living alone with no formal care services but family support. Background of diabetes, OA, osteoporosis, fibromyalgia, pseudo gout, cataracts Referred to CPAT by her GP with reduced mobility (unable to weight bear), pain in her lower limbs and not eating and drinking for 2 days Diagnosed with UTI.

13. Assessment at Home Assessed by CPAT at home who referred her to bed based rehab as no hospital admission needed but not safe to stay at home. Admitted to bedded unit the same day Needing assistance with personal care and meals

14. On admission Assessed by therapists, required assistance of 2 people and rollator frame to transfer. Not able to mobilise Barthel 8/20 Developed pressure area on heel due to prolonged period in bed, seen by tissue viability nurse Liaised with temporary GP to manage pt’s pain and started antibiotics for UTI Rehab plan agreed with pt and daily exercise sessions commenced

15. Treatment Encouraged pt to complete personal care as independently as able Practiced meal preparation in breakfast group Daily exercises Mobility practice Stair practice Home visit after 3 weeks input needs identified for discharge Wound care

16. On discharge Pt able to transfer and mobilise independently with equipment Managing personal care and meals independently Managing stairs with supervision from family Barthel 19/20 UTI resolved, pain under control and pressure sore had healed Referred on to HARI for further rehab and district nursing to monitor pressure areas Total length of stay – 4 weeks

17. Contact details Community Rehabilitation Team Wilson Hospital Cranmer Road Mitcham CR4 4TP Screener’s phone: 0208 687 4593 Fax: 0208 646 6408 Sutton and Merton Community Services Administration Centre SMCS Administration Team PO Box 70926 London SW19 9FS T 0845 567 2000 E rmh-tr.smcsadmin@nhs.net F 020 345 85 888 Sutton and Merton Community Services Administration Centre SMCS Administration Team PO Box 70926 London SW19 9FS T 0845 567 2000 E rmh-tr.smcsadmin@nhs.net F 020 345 85 888 CPAT Tel: 02082510152

18. Thank you