Regional Reablement Workshop
Nicholas Smith and Carol Cottingham
Friday 26 March 2010
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Regional Reablement Workshop
Integrated Intermediate Care System
On a journey..
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What we have now...
• Intermediate Care – Commissioning Framework 2009
• Lincolnshire NHS Community Services Community Response and Rehabilitation Team (CRRT) with ASC funding and staff contribution
• Stroke Rehabilitation Services
• Fast track end of life care (St Barnabas)
• Hospital District Nurse Liaison and ASC hospital discharge teams
• Lincoln County Hospital Fast Track Continuing Health Care assessments
• Adult Social Care Assessment and Re-ablement Service (LARS)
• LPFT OP dementia hospital Liaison Service and Intermediate Care Service
• Voluntary organisations ‘home from hospital’ services
Regional Reablement Workshop
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Regional Reablement Workshop
LARS
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Regional Reablement Workshop
Lincolnshire Assessment and Reablement Service (LARS)
First Contact / Initial Assessment Customer
Service Centre
NFAor advice/
Informationonly
LARS Service Case Management
Screening &Allocation
Referral fromWard
Hospital Discharge
Team
Health RehabServices
(eg Stroke)
Prevention Support viaVoluntary
Organisations
Intermediate Care(Community &
Beds)Reablement
Rapid Response and
Interim Care
Long-termAssessment(RAS) and Discharge
Clinic-basedAssessment(Equipment/
telecare)
Long-termAssessment(RAS) andDischarge
NFA servicescomplete
Transfer to Long-TermMaintenance
Assessment & Care ManagementBrokerage (support planning, review,Case management, reassessment)
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Regional Reablement Workshop
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Regional Reablement Workshop
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Prevention and Early Intervention
Regional Reablement Workshop
Practical Steps
• Set up an Intermediate Care Board with clear terms of reference and accountability
• Use and build upon existing ‘Framework Agreement’
• Identify elements to build up a Pooled Fund:- Intermediate Care beds- LARS- CRRTs- LPFT – Dementia Intermediate Care Service
• Publish a strategy (6 months), Action plan to reshape
• Use HWB fund to help shift resources to enable Intermediate Care System to support and assess people identified at risk of NHS Continuing Care Service
• Determine bed base for crisis support, assessment and rehabilitation service
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Regional Reablement Workshop
Cont’d
• Determine community resources for an crisis support, assessment and rehabilitation service
• Ensure pathway clear so right person offered right service mix
• Empower Case Managers as accredited Trusted Assessors for both agencies to create individual ‘intermediate care’ packages drawing from different services
• Look at developing shared skill base around rehab/support workers
• Operational shared accountability, governance and performance
• Involve Service Users/Patients/Families and Clinicians in service redesign
‘An exemplar for joint commissioning that delivers, improved outcomes, improved co-ordinator, more effective and efficient use of resources’
