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Right Therapist, Right Time : Collaboration and Partnership Barbara Stoker Clinical Director Integrated Therapies Right Therapist, Right Time : Collaboration and Partnership Barbara Stoker Clinical Director Integrated Therapies

Integrated Partnership Integrated Partnership

2013……………. . Change Maintaining partnership stability Protect Prevent Reduce Impact Defend Clinical skills; expert 2013……………. . Change Maintaining partnership stability Protect Prevent Reduce Impact Defend Clinical skills; expert knowledge; planning Integrated working; training Essential Core competencies service delivery Future Proofing ? Future markets ? Future funding ? Future proof resources Uncertainty

Strengths • • Proactive Person Centred Skilled staff and resources Consistent approach across the Strengths • • Proactive Person Centred Skilled staff and resources Consistent approach across the service Recruitment of high calibre staff Flexible workforce Partnership Board

Attitude is a little thing that makes a big difference. (Winston Churchill) Attitude is a little thing that makes a big difference. (Winston Churchill)

Service Improvement Maintaining Partnership stability Reduc e Impact Protect Prevent Defend Clinical skills; expert Service Improvement Maintaining Partnership stability Reduc e Impact Protect Prevent Defend Clinical skills; expert knowledge; Planning Integrated working; training Core competencies service delivery Essential Future Proofing Future markets Future funding Future proof resources Staff Development

Common Aims • • • Prevent avoidable hospital admissions Prevent admission to care home Common Aims • • • Prevent avoidable hospital admissions Prevent admission to care home Reduce length of stay Reduce social care waiting lists Take care (therapy) closer to home = Rehab

Oscar Wilde said……. There is only one thing in life worse than being talked Oscar Wilde said……. There is only one thing in life worse than being talked about, and that is not being talked about. So it was time to make some noise!

Shaping Future Services • Capacity and demand in community services • Identify gaps and Shaping Future Services • Capacity and demand in community services • Identify gaps and consider the impact • • Where is the money to support development/change? Information & data • Representation at all levels • The right ‘currency’ to use – what do you count? – Sampling/walkabout/new: review/levels of rehab – Tolerate and wait – Moniter and collect data – Measure the impact and report (service plan) – Everyone needs a ‘Jayne’ (performance pictures) – Targeted groups/meetings/people – hard & soft sell

Prevent avoidable hospital admissions: A&E Therapy • • • Funding SHA CCG winter BCF Prevent avoidable hospital admissions: A&E Therapy • • • Funding SHA CCG winter BCF Supporting metrics – – – Referred Discharged Assessment & Level Follow up Age - Response time - Discharge destination - Outcome - Patient story samples - Activity sample weeks Reports completed to increase capacity 8 am – 8 pm 7 days Supports A&E/AAUs Direct access to Rapid Response/PCH beds/Intermediate Care/Reablement/Community Rehab

Prevent avoidable hospital admissions: Rapid Response Therapy • • Commissioned by CCG but funded Prevent avoidable hospital admissions: Rapid Response Therapy • • Commissioned by CCG but funded with nursing Limited funding for therapy 7 day service • Rapid Response equipment package training provided to nursing and sub store access to prevent hand off Referrals via central point • – Staff consultation 7 day community – 7 day with 5 day funding – 8 am – 8 pm – Now permanent (STees CCG)

Prevent admission to care home: Reablement Middlesbrough Redcar & Cleveland • • Reablement provided Prevent admission to care home: Reablement Middlesbrough Redcar & Cleveland • • Reablement provided in house to follow up discharge from Intermediate care and provide specialist reablement Direct access to community rehab Out sourced Human Support Group. – Provides OT & support workers – Integrated Therapy provides training – Operational group chaired by social care OT • • Rablement in house. Therapy provided by Integrated Therapies Redcar Reablement Unit – 7 day therapy seconded. Activity Therapy directed. Pilot extended further 18 mths Direct access to community rehab

Reduce Length of Stay Middlesbrough Redcar & Cleveland • • Reablement Time 2 Think Reduce Length of Stay Middlesbrough Redcar & Cleveland • • Reablement Time 2 Think – – – Yr 1 health commissioned local care home with Integrated Therapies Yr 2 social care commissioned alternative provider Yr 3 health commissioned local care home with Integrated Therapies 6 beds dementia 14 assessment/recovery beds Access via Single Point of Referral Rablement Discharge Decision not made. – – Assessment/recovery beds commissioned by social care from care homes Integrated Therapies via Reablement with direct access to community rehab

Reduce Length of Stay: Early Supported Discharge (ESD) Stroke • • Stroke pathway commissioned Reduce Length of Stay: Early Supported Discharge (ESD) Stroke • • Stroke pathway commissioned by Stees CCG via IMPro. VE programme Closure of 2 x community bed bases reducing beds from 18 to 12 Staff consultation to provide 7 day stroke rehab within PCH and ESD. Recruitment to ESD Completed within 12 weeks Completes pathway from acute community to social care Collaboration with social care reablement to provide on going support Pushed the rehab debate for trauma, neuro and complex cases

Reduce social care waiting times • Impact on social care of treating people at Reduce social care waiting times • Impact on social care of treating people at home is often overlooked, e. g. specialist equipment, housing adaptation • • • Increasing demand v fluctuating capacity • • New computer system Increase in complex cases – – – Adapted social work complexity tool to provide common understanding Monitor caseloads through regular snap shot caseload analysis Performance report through Partnership Board Care Act Increase in staff resource (non recurrent funding)

Skills sharing • • Equipment – Self assessment of competency – Levels of training Skills sharing • • Equipment – Self assessment of competency – Levels of training provided – Themed packages – Equipment prescribing - widening permission – Nurses/Social Workers/OTs/Physios/Support staff Next – Respiratory – Dementia – Stroke – MSK

Top Tips • Building a set of metrics that support the messages and if Top Tips • Building a set of metrics that support the messages and if you havent got one find a ‘Jayne’ • • Invest / nurture project leadership • • Build skills into the workforce which reflect the make up of your area. Annual service plan – Staff/Service Delivery/Quality/Development Use representation at every level Look for the gap and make a business case for this regardless of who will provide as the right service in place benefits everyone Pathways should lead on to networks of support to prevent relapse, social isolation and ensure community reintegration

For the patient/customer • • • Services funded separately but these are connecting up For the patient/customer • • • Services funded separately but these are connecting up across STees health and social care Whole system to meet need and provide choice There are still gaps most notably in community rehab but through the CCG IMPro. Ve programme there is to be significant investment in community therapy to provide rehab close to home. This will include 7 day PCH, rehab coordination, single point of access, higher level of rehab in a person’s own home

Its all happening……. The right time is now! Its all happening……. The right time is now!