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www.england.nhs.uk
A collaborative approach to
rehab, reablement,
recovery, survivorship &
prehab in the SW
Ruth Hall, Quality Improvement Programme
Manager
SCN
August 2014
www.england.nhs.uk
• For system stakeholders to work with the SW SCN on plans to develop a single commissionable rehabilitation pathway in the South West that is focussed on:
• The understood needs of people.• Safe, high-quality care that reflects learned good
practice and makes the best use of scarce resources.• Equity and consistency.• Transparency for patients
Purpose
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• Address ad hoc nature of service• Great synergy across services• People centred/transparency Outcome focused• Optimise potential of proactive rehab in following
areas:i. managing of LTC
ii. care management after sudden onset incident
iii. living with and adjusting to impact of illness and/or injury
By
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• Pockets of best practice• All condition specific• Historically worked in silos • So why change it?• It is a priority• People are living longer and rarely have 1 condition• Not all our patients getting the right rehab• Balance between specialist and generalist therapy not
meeting the need• But enthusiasm in SW to improve services
South West
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• SW Project Group • Clinical champions & clinical lead• Two half day pre-meets in May• 2 day event 1st and 2nd July• Multi agency – LA/Health/PH….• Learn from forerunners in SW ie South Gloucs,
Symphony, Pioneer Projects
How is it being moved forward?- what has been done
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• Now in implementation stage• Circulate pathway to SW as output of event• Take up offers of help for the work stream from 1st & 2nd
– project groups/work streams• In September write to commissioners: with the pathway for inclusion in the commissioning
intentions pull out what is distinguishable about this pathway what still needs to be done – costing the pathway, tools
to support commissioners,
How is it being moved forward? cont.
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The things we think need to be done
7
In 3 years, when the
changes we are planning
for rehabilitation
have been fully
implemented and bedded in
In Jul when our joint
session has established a
core rehabilitation pathway that
has been developed by (and is now owned by)
the SW system
Governance and Programme Management: Lead and manage the programme,
constructing the compelling case for change
Performance and Finance: refine and cost the core pathway, establish the business case (showing how
money follows the patient across the system)
OD: Develop a system / organisational design that supports equity and consistency in future
commissioning
Communication and Consultation: engage and align the whole integrated system / supply chain
1
2
3
5
Programme Group
Evaluation of the pathway
4
www.england.nhs.uk
The person-centred rehabilitation lens
Personal
Rehab Plan
Managed conclusion of formal rehabilitation care and
supportThe person, their carer
and family in their community
Joint, collaborative assessment of need, options, choices, outcomes, incentives,
management
First single
POC
Acute / community in-patientrehab plan
Complex home rehab
plan
Home rehab plan
Educatio
n
Re-assessment
Monito
ring
Feedback
Incentives
Self-management
Carer views
Innovati
on
Tech
nolo
gy
Sustain
ability
Continuous assessment
and improvem
ent
www.england.nhs.uk
Thank you for listening
Any questions?
How would you like to be involved and kept informed?
07796 994459