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A collaborative approach to

rehab, reablement,

recovery, survivorship &

prehab in the SWRuth Hall, Quality

Improvement Programme Manager

SCN

August 2014

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• 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 LTCii. care management after sudden onset incidentiii. 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

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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

Educa

tion

Re-assessment

Monitoring

Feed

back

Incentives

Self-managementCarer views

Inno

vatio

n

Technology

Sustainabilit

y

Continuous assessment

and improvement

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Thank you for listening

Any questions?

How would you like to be involved and kept informed?

Ruthhall@nhs.net07796 994459