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Full Report on

Rehab and Enablement Project

Jointly developed by

NHS Grampian and Aberdeenshire Council

August 2014

Contents Page

Executive Summary.........................................................................................................2

Background and Introduction...........................................................................................4

Data and Discussion........................................................................................................7

Service User and Team Experience..............................................................................18

Projected Cost Benefit Analysis.....................................................................................21

Conclusion and Recommendations...............................................................................25

Appendix 1 Rehabilitation and Enablement Process.................................................33

Appendix 2 Goal Setting............................................................................................36

Appendix 3 EQ – ED – 5L.........................................................................................38

Appendix 4 Homecare Handout................................................................................41

Appendix 5 Key Findings RGU Study........................................................................43

Appendix 6 Unit Costs...............................................................................................46

Appendix 7 Scenario 1 Reduction in Home Care....................................................47

Appendix 8 Scenario 2 Minimisation and Home Care Services..............................50

Appendix 9 Scenario 3 Avoidance of Hospital Admission.......................................52

Appendix 10 Scenario 4 Avoidance of Residential Care...........................................55

Appendix 11 Scenario 6 Reduction in Hospital Stay.................................................58

Appendix 12 Enhanced Data.......................................................................................61

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Executive Summary

Aberdeenshire Council and NHS Grampian/Aberdeenshire Community Health Partnership (CHP) put forward a joint bid to the Aberdeenshire change fund in mid 2011 to develop enablement, sometimes known as re-ablement. The pilot areas were Turriff, Peterhead and Inverurie. Other examples of enablement were in existence in Scotland however the majority were single Local Authority service projects. In 2011 with the upcoming integration agenda Aberdeenshire council and NHS Grampian were keen to further develop close working and joint service responsibility/single system working.

The Aims of the Aberdeenshire Joint Project were:-

Test via pilots the strengths and weaknesses of an integrated model of rehab and enablement delivered by a multi-disciplinary team.

To determine the cost effectiveness of rehab and enablement services using the chosen model.

To determine service users’ perceptions of rehab and enablement. To determine the impact of rehab and enablement on home care

capacity.

The multi-disciplinary, multi agency teams comprised of: Home Carers, Local Authority Occupational Therapy (OT), Physiotherapy, health OT, District Nursing and initially Care Management. Additionally each project had a small amount of admin and a team coordinator/lead. The intervention would be 4-6 weeks in duration.

The project was externally evaluated by the Robert Gordon University. The majority of feedback has been positive from service users and their informal carers.

The most keenly felt and positive aspect of the REACH pilots was the value placed on the impact of the intervention by service users in terms of improvements to their independence and confidence.The success of the intervention was felt to be due to a large degree to the method of delivery and the interplay of three components;

o Time – the capacity for care staff to provide the time required to support intensive rehab and enablement interventions, the flexibility and speed by which interventions could be arranged between different professions and care plans altered accordingly to meet service users’ capacity.

o Targeting – the targeted nature of intensive intervention over a matter of days or weeks for those service users assessed as capable of benefiting.

o Teamwork – the close communication between carers and the key professions of Occupational Therapy, Physiotherapy and District Nursing, ensured flexibility and timely response of services, tailored to the changing ability and capacity of the service user on a day to day basis.

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The following recommendations for action are put forward to the Health and Social Care Partnership:

Continuation of training for all home carers and practitioners on rehab and enablement through e-learning, induction and further training of all CTCs, LACs and Care Managers.

Goal Setting is adopted by all MDTs involving the service users and/or carers. This will involve developing training on goal setting/utilising existing goal setting training delivered to all MDTs as part of planning for integration.

Relevant information developed and used to inform the wider staff group and local community. This requires development of information in all formats i.e. written, web based etc.

The role of homecare service as part of an enabling structure considering the flexibility of service delivery required for rehab and enablement.

Move from a predominately discharge model to an inclusive mainstream intake model i.e. Service users in need of assessment or at service review, are functionally assessed and considered for rehab and enablement intervention as appropriate.

Consideration that commissioning is essentially a task focused process so engagement with those commissioning services to determine how an enabling ethos and specific rehab and enablement programmes can be integral to commissioning.

Improving the relationships and communication links between the home carers and the MDT considering how home carers can be part of MDTs.

Engagement with third sector to consider co-production and involvement in pathways.

Explore the implications of the local authority charging policy.

Paperwork review in line with integration and pathway work.

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Rehab and enablement

Background and Introduction

Aberdeenshire Council and NHS Grampian/Aberdeenshire Community Health Partnership (CHP) put forward a joint bid to the Aberdeenshire Change Fund in mid 2011 to develop enablement, sometimes known as re-ablement. The term enablement was chosen because of the dictionary definition: Enable – “supply with means (to do); make possible”. Other examples of rehab and enablement were in existence in Scotland however the majority were single Local Authority service projects. In 2011, with the upcoming integration agenda, Aberdeenshire council and NHS Grampian were keen to further develop close working and joint service responsibility/single system working. As the legislation around integration has since emerged this approach has been validated. Government priorities highlighted in the Christie Commission report promoted independence and integration in health and social care services. The Scottish Government’s Reshaping Care for Older People policy to enable older adults to stay in their own homes for longer supported by an increase in service users’ independence and reduction in their care needs is supported by rehab and enablement services.

Of the Scottish examples, the models used are split between a Stand Alone Rehab and enablement service and an Integrated Rehab and enablement Service (n=25 and n=5 respectively).

Concept Approach- rehab and enablement ethos embedded within local authority service rather than specific stand alone teams.

Continuity Model- dedicated rehab and enablement staff are deployed to work with service users for specified time periods. More commonly seen in rural areas.

The bid initially was for two projects, Turriff and Peterhead with multi-agency staffing. The initial allocation of funding was £530,00 , the largest single allocation of funding from the change fund. The Aims of the Aberdeenshire Joint Project were:-



To determine service users’ perceptions of rehab and enablement. To determine the impact of rehab and enablement on home care capacity.

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The multi-disciplinary, multi agency teams comprised of: Home Carers, Local Authority Occupational Therapy (OT), Physiotherapy, health OT, District Nursing and initially Care Management. Additionally each project had a small amount of admin and a team coordinator/lead. A process document outlining parameters for the service was drawn up (Appendix 1). The intervention would be 4-6 weeks in duration. The team coordinators were both OTs and therefore seen as having appropriate skill sets to lead on functional assessments. A third project was added in September 2013 at Inverurie, with a team coordinator/lead drawn from care management, who also had an OT background. Of the coordinators one OT was from local authority mainstream OT service and one from health, community rehab services, plus one was from local authority care management.

First steps were taken to agree a common language across organisations so rehabilitation and enablement in Aberdeenshire were defined as follows:

Rehab and enablement – is a time limited intervention that supports the person and/or carer to achieve set goals to support the maximising of independence and community involvement whilst reducing reliance on traditional forms of social care support.

Rehabilitation – the process of restoration of skills and function of a person who has had an illness or injury so has to regain maximum independence, self- sufficiency and function in as normal or near normal manner as possible.

Enablement and Rehabilitation can be seen as different interventions on the same continuum. In addition understanding that intermediate care is on the continuum and can be defined as “focused on prevention, rehabilitation, re-ablement and recovery, delivered by a collection of services working to common, shared objectives and principles.” Understanding the definitions places Aberdeenshire CHP rehab and enablement projects in context.

It is recognised that the terms enablement, re-ablement or re-enablement have all been used in similar projects nationally. This confusion over definitions have arisen as neither the UK government or Scottish government have clarified their own definitions. It also means that comparing projects can be problematical if different definitions and parameters were used.

Establishing the projects:

Initial awareness training was delivered to home carers in the project areas. This was delivered by practitioners involved in rehab and enablement but laterally, to be sustainable in the longer term, delivered by the training department of Aberdeenshire

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Council. The awareness programme was also made available to community hospital staff and all practitioners who would be involved.

Dedicated teams were established in the project areas. Staff were recruited either directly to the projects or released via backfill.

Required paperwork was developed, supporting goal setting (Appendix 2) with service users and provide guidance for home carers who were to be delivering the service. Home Carers were to be the therapy partners or deliverers of the intervention, the strong rehabilitation focus in the projects were delivered by Occupational Therapy and Physiotherapy, and case management and medicines management support was provided by community nursing. Permission to use the European outcome measure EQ-5D-5L was gained. The EQ-5D-5L measures health outcome and has been used in many of the early rehab and enablement projects as an outcome tool (Appendix 3).

Significant drivers supported the development of rehab and enablement in Aberdeenshire. Rehab and enablement moves from a task-orientated approach where established users receive a package of care often for long periods with little or no reduction in their levels of care. Rehab and enablement moves to a needs-led approach focussed on service users’ strengths and abilities where they, and their families, play a key role in the care accepted. By actively involving service users with the aim to increase their independence a culture of “work with” rather than “to do for” is about maximising service users long term independence and quality of like and also appropriately, minimising ongoing support required and thereby minimising the whole life cost of care. The rehab and enablement programme links closely with the self-management agenda and also self directed support which requires the multi-disciplinary team to ensure the service users is central to any intervention and is a decision maker around their rehabilitation and care.

Evaluation of Re-ablement/enablement services has varied greatly across the UK, and outcome measurements are not uniform and can include Outcome Based Measurement (OBA), such as a reductions in care packages or reduction in Delayed Discharge etc.

The success of rehab and enablement programmes is tempered by the inability to accurately measure outcomes, starting from different definitions and parameters and variable ways to consider cost effectiveness.

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Data Discussion

Referrals:

Source

The Rehabilitation and Enablement in Aberdeenshire for Care at Home (REACH) criteria was determined as individuals who were able to, and had the motivation, to participate in setting goals.

Typical sources of referrals were : Hospital nursing and Allied Health Professions staff, Community Nurses, Acute Sector OTs (e.g. Stroke Unit), Mental Health, Care Managers and LACs, Families, Client self-referral through ‘word of mouth’, GPs (variable across localities).

Insufficient advertising of the service may have limited the number and source of referrals.

REACH referral criteria was felt to be unclear resulting in some referrals being made inappropriately e.g. attempts to circumvent lack of availability of main stream home care; faster access to Social Work OT or NHS community Allied Health Professionals; discharging patients from hospital whose discharge was otherwise delayed.

Age range

The youngest service user involved was 43, the oldest 97.

Large numbers of service users in their 80s and 90s achieved success through REACH because of their stoical, well-motivated, self-reliant nature. Conversely others in this age range had less successful outcomes due to frailty and multiple co-morbidities (health problems).

At the younger end of the scale, service users were more expectant of ‘services being provided’ and an ‘entitlement’ to assistance, a cultural expectation.

Gender

The numbers referred were broken down as 319 female:159 male.

Numbers rejected/service users refused.

The numbers of service users referred who were not accepted into REACH is detailed in the data and is 28.9%. Of those who did participated in a REACH programme the number who did not complete is very small.

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Service users found to be medically or psychologically unfit to engage with REACH. This included those with a cognitive impairment who are unable to recall information from one session to the next, and those with no motivation to engage with the service.

Service users who clearly had no significant rehabilitation potential which could change their outcomes for care or had a previously established home care package and no scope for reduction in home care.

For some service users referred to REACH, their independence and reablement could be quickly and easily addressed through a single intervention or by a single discipline e.g. a OT or physio, without the need for intensive intervention involving a multi-disciplinary team and home care staff.

Average/median length of stay

Short duration of REACH usually indicated the service user’s need for resettlement into home situation and routine, with re-orientation and confidence boosting.

The average length of stay was 6 weeks, as initially expected, and suggests appropriate goal selection matched with service users’ conditions and abilities.

Longer than average stay was a result of various factors: client’s function improving more than expected resulting in additional goals being set and accommodated; an acute medical event, such as a fall, infection; planned hospital admission where resuming and extending duration of REACH resulted in overall faster recovery; waiting for installation of adaptations which, with practise from REACH team members, service users could then make use of independently; supporting service user through moving house to establish and maximise independence and thus reduce home care needs in new accommodation; supporting a new permanent wheelchair user, following a long hospital stay, into new accommodation; waiting for mainstream home care to become available. These complex situations could have been expected to require REACH input for longer, but will ultimately maximise client abilities and minimise home care input in the longer term.

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Completion of REACH

Reasons for non-completion of REACH included service users becoming seriously ill or dying; change in medical condition resulting in admission to hospital or long term care; service users agreeing to REACH plan and philosophy in order to secure discharge from hospital with rehab and enablement support, then showing a different agenda once home; client choosing to discontinue REACH; possible unachievable goals set by client .

Repeat Clients

These were predominately self-referrals, by service users or their families following a previous successful intervention from REACH, in the event of further health issues and seeking appropriate support for recovery.

Reduction in Home Care

Only 31% of participants had home care prior to REACH intervention. Service users were referred to REACH as an alternative to organising a standard care package following a change in their health/abilities. It is difficult to quantify, in cases that had no home care before REACH, but in many instances, it can be projected that individuals have smaller packages of mainstream home care because:-

Mainstream home care requested on completion of REACH was specific and focussed on service users’ assessed and proven need, following a period of reablement, rather than service user/family/other professionals’ perception of need.

The entire REACH multi-disciplinary team is service user focused and home carers, who delivered much of the interventions directed by the MDT, were supported to encourage client participation and identify progress and reduced need for input. Home Carers were part of the MDT in REACH and have ready access to the practitioner guidance on each individual client.

Other benefits of REACH

REACH proved successful in pinpointing in service users’ baseline functioning, both physical and cognitive, setting achievable goals and determining onward referral to appropriate specialist services and agencies.

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REACH demonstrated an increase in individuals self-reliance and initiative by referring on and/or empowering clients to access third sector/ community services, i.e. Dial-a-bus, Signposting, dog-walking, library, RVS, foot care, hairdresser, supermarket buses, online shopping, community exercise groups, VSA carers centres, creative breaks, CAB/GRAIN, attending GP surgery for appointments rather than requiring home visits.

EQ 5D 5L is a standardised instrument for use as a measure of health outcome. It is applicable to a wide range of health conditions and provides a simple descriptive profile and single index value for health status. As a health outcome measure it has been used in several studies on enablement/re-ablement. A significant proportion of our service users undertook an EQ 5D 5L at both the start and end of interventions. Measured as a single number the service users rated their health status as improved or the same in 89% of interventions.

Brief summary of EQ 5D 5L results.

Score Episodes Percentageimproved 133 82%same 12 7%decreased 18 11%Total 163

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Data Analysis

REFERRALS

PROJECT NUMBER OF REFERRALS

InveruriePeterheadTurriff

16422787

Grand Total Including second referral for the same individual (33 referrals) 478

The numbers of referrals reflect the populations in each of the project areas, practice populations of 22k, 21k and 8k respectively. Inverurie commencing the project after Peterhead and Turriff.

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Service Users

TEAM NUMBER of Service Users


12715562

Grand Total 344

The percentage of service users not accepted onto the project is broadly 28%.

REPEAT SERVICE USERS

Number of Repeat Service Users.


13173

Grand Total 33

Repeat clients often came as self referrals having had a previous positive experience with REACH.

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LENGTH OF SERVICE IN WEEKS

NUMBER OF CLIENTS TEAM

LENGTH OF SERVICE INVERURIE PETERHEAD TURRIFF GRAND TOTAL

One to Two 17 48 8 73

Three to Four 28 29 10 67

Seven to Eight 14 21 10 45

Nine to Ten 13 11 3 27

Eleven and Over 12 16 4 32

Ongoing 6 5 7 18

DNC 8 3 11

Grand Total 127 155 62 344

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AVERAGE LENGTH OF SERVICE IN WEEKS

Inverurie Peterhead Turriff

Overall201220132014

6564

6576

6565

MODAL LENGTH OF SERVICE IN WEEKS


Overall201220132014

3135

2612

636

n/a

Both the average and modal length of stay are broadly what was intended 4-6 weeks.

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MAX/MIN LENGTH OF SERVICE IN WEEKS


Overall201220132014

20/120/117/16/3

33/112/133/119/1

14/114/113/18/2

N.B. n= 315 as remainder pf service users are DNC or Ongoing

At times on each of the projects it has been difficult to progress specific patients onto mainstream homecare. This has been for a variety of reasons.

Turriff service user not reflected in numbers as he was at 29 weeks when we finished the project.

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1.0 HOME CARE

31% of sample was in receipt of home care when commenced on the REACH programme i.e. The majority of service users had no homecare previously and were referred when a homecare package was about to start following a hospital admission.

Discharged To Total Percentage of Overall Service Users

Lower 11 3%

Same 23 7%

Higher 72 21%

Discharged to Higher Level Under 65 65-74 75-84 85 and Over

1 4 9 22

0 2 6 17

2 0 2 7

Total 3 6 17 46

Discharged to Lower Level Under 65 65-74 75-84 85 and Over

1 1 1 4

0 1 0 2

0 0 0 0

0 0 0 1

Total 1 2 1 7

Discharged to Same Level Under 65 65-74 75-84 85 and Over

1 1 4 6

0 0 1 2

1 0 3 4

Total 2 1 8 12

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1 Awaiting Mainstream Home Care.

3 receiving home care prior but did not complete REACH.

1 Ongoing service user.

REACH Base

Service Users ReferralsAdmissions Pre

ReferralAdmissions Post Referral

Turriff 2012 37 40 0 8

Turriff 2013 36 36 22 9

Turriff Total 73 76 22 17

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Service User and Team Experience

To develop multi-disciplinary multi agency teams consideration was given to the roles of the team members and the training required. Initial awareness training was delivered for home carers in the pilot areas, the awareness programme was developed across health and social care, delivered in a two hours session involving a small amount of practical work and well as discussion and was followed up with a handout (Appendix 4). The home carers were engaged in the session generally with some home carers understanding the concept of “support to do with” rather than “do for” others expressing concerns that they couldn’t stand back and watch a client struggle and they were being paid to help. From the initial awareness the home carers were asked to self identify if they were interested in being part of the pilot projects, additionally Care Team Coordinators (CTC) identified specific home carers they felt would be suited to the change in ethos.

The identified home carers were then allocated to the projects and started a period of on the job training. This took the form of shadowing other team members and receiving tutorials and guidance in specific skills. This was reported by the home carers, as being extremely valuable when learning new skills and techniques. In hours, per home carer, this equated to approximately 30 hours individualised training. As we consider the mainstreaming of rehab and enablement it was clear this was unsustainable as there are over 700 local authority home carers plus outside agency staff. The awareness raising session can be delivered by the Local Authority training team. Additionally an extensive e-learning resource has been developed featuring Service Users, and staff from the pilots. The resource is held on Aberdeenshire Council’s intranet system with special arrangements to allow access also to health staff. The e-learning modules are all short bites of information covering different practitioner roles and the experiences of home carers involved in the pilot projects.

A Roles Co-ordinator for each project as detailed in the introduction undertook most of the initial assessments with new service users, and coordinated the different practitioner inputs. Additionally the coordinator, alongside CTCs scheduled the home carer involvement in the projects.

Occupational Therapy from both health services and local authority services provided assessments of functional abilities, goal setting with service users, and support for the home carers delivering the agreed intervention. Whether it was health OT or social work OT depended on where the service users were referred from. The majority of service users, in our projects, so involved health OT primarily.

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Physiotherapy focused around supporting service users to improve and increase mobility, strength and balance and providing direction to the home carers in how this could be enabled.

Where involved, District Nurses, provided a key role in supporting medicines management and broad health needs of service users.

Care Management was initially identified in the proposal but not included in the team. The reason for this being due to the intensive case management approach of the coordinators role resulting in less requirement for Care Management. Additionally the ultimate care packages were straightforward and could be instigated by a Local Area Co-ordinator (L.A.C). Lack of CTC sitting within the teams, led to difficulties around the line management of and scheduling of work to home carers. This component of the team was not considered as necessary during the proposal stage however as the projects progressed it became clear that the team had a need for a care team coordinator.

The service user experience was considered and evaluated in depth by Dr J Love of Robert Gordon University and the key findings are (Appendix 5). Key to any evaluation are service users’ experiences, thoughts and views. The study captured the views and experiences of three key groups involved in the REACH projects: older people using the REACH service; the relatives and carers of older people using REACH services; and the teams involved in providing services through REACH.

REACH service users identified:

REACH was available at the time of need. The practical support REACH could provide was seen as attractive. Access was easy. The initial assessments were thorough and accurate. Goals were met at the point of discharge from REACH. The value of increasing independence and re-gaining independence The value of attaining or retaining confidence in their abilities

Informal carers valued about REACH:

Achievement of full or partial independence for the person they looked after. Practical supports offered. Increase in confidence of the person they provided care for.

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The team members highlighted about REACH:

The positive of having more time to spend with service users. Faster and better supported hospital discharges. Selective targeting of appropriate service users. Better team working. Improvement in service users’ quality of life and confidence. Less volume than anticipated. Initial uncertainly around differing NHS and Local Authority OT roles. Mainstream services’ awareness and knowledge of the projects and what was

being offered. With the service users’ permission, the involvement of family and informal

carers in the design and on-going development of care packages. The availability of all required staff at all times was difficult at times. The positive up skilling of home carers. The main strengths summarised as timeliness, rehab and enablement

philosophy, reduction in the need for long term support, secondary mental health benefits and support for families.

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The Relative Value of REACH Interventions – a projected cost benefit analysis

The RGU research shows that REACH provided positive outcomes for service users and their carers, restoring and often enhancing independence and feelings of self-confidence.

But what can we say about the financial benefits of REACH intervention to service providers?

This section provides some evidence, in the form of case studies against likely outcome scenarios, of the potential financial savings that could be achieved through

REACH interventions, in contrast to current or traditional alternative interventions.

The following six outcome scenarios were identified that may apply to REACH service users:

1. Reduction in home care services – service user who received a home care service prior to REACH and following REACH intervention their home care service needs were reduced.

2. Minimisation of home care services – service user whose need for ongoing home care services following REACH intervention was less than would have been the case had REACH not been available.

3. Avoidance of hospital admission – service user who would likely have been admitted to hospital had there not been REACH intervention.

4. Avoidance of residential care (e.g. care home) – service user who would likely have entered residential care had there not been REACH intervention.

5. Reduction in burden of care for unpaid carer – service user who’s unpaid carer would likely have had a larger caring role had there not been REACH intervention

The estimated savings in these case studies are not presented as fact, but rather hypothetical projected savings based on the use of known costs and professional judgement on the likely alternative outcome for clients, had Reach not been available. They serve as an illustrative tool for where the scope for the greatest financial savings may lie for service providers, going forward.

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6. Reduction in hospital stay – service user who would likely have had a longer stay in hospital had there not been REACH intervention.

Against five of these scenarios, one “typical” case study was drawn from the clients who had received REACH services. A case study was not drawn for scenario 5.

For each case study, a comparison is made of the financial cost for service providers of the REACH intervention, as against the estimated cost of the projected, or hypothesised, alternative outcome, had there been no REACH intervention for that service user. Where the provision of care within the community is involved (e.g. residential or home care), the costs are projected based on one calendar year. The difference between the two costs is the anticipated saving for public service providers from REACH intervention– as in each case study the REACH intervention proves cheaper than the projected alternative, based on the methodology and assumptions used.

Methodology

A brief summary of the service user’s condition and ability (before, during and at conclusion of REACH) is provided.

Against this, two definitions of the cost of the REACH intervention is provided.

The first definition uses a unit cost (Appendix 6) of the REACH staffing costs for each pilot project (Peterhead, Turriff, or Inverurie). This unit cost is derived simply, and somewhat crudely, by dividing the total number of service users receiving the service from that pilot project during 2013 by the total staffing cost during 2013/14 for those staff funded through OPSOG funding (both NHS and LA staff) for the pilot project from which the case study is drawn.

The second definition (and which is the definition used for the comparison with the projected alternative cost) uses the client specific actual REACH staffing cost relative to that case study (ie, if 3 hours of REACH OT input were used, that along with the other REACH staffing costs was calculated)

Where equipment is prescribed as part of the REACH intervention, those costs are included in the REACH cost. Where ongoing care (e.g. home care) is incurred at exit from REACH, the costs of that are included in the REACH cost, and projected for 1 calendar year.

Summary Findings

For each of the case studies where a financial comparison was calculated, the projected costs savings were as follows:

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1. Reduction in home care - £6,618.41 (year 1) (Appendix 7)

2. Minimisation of home care services - £10,459.06 (year 1) (Appendix 8)

3. Avoidance of hospital admission - £2,084.56 (Appendix 9)

4. Avoidance of residential care (e.g. care home) - £24,546.45 (year 1) (Appendix 10)

5. Reduction in hospital stay - £5,746.66 (Appendix 11)

The case studies, particularly in relation to reducing or minimising home care, serve to illustrate the way in which the more ‘expensive’ resources of OT and Physio staff time (relative to home carers) has been able to be minimised, while still enabling intensive input for service users. Predominantly this has been achieved via the staffing and communication models used, whereby close, often daily, communication and update between home carers and OTs or Physios enables plans and goals to be monitored and modified, in response to service users, without the need for direct, repeated interaction between service users and the OT or Physio staff. Not only does this approach cost less, but it speeds up the delivery of services and the capacity to respond quickly to service user needs and abilities.

Cumulative cost savings

A final exercise was undertaken to calculate the cumulative hypothetical financial savings to public service providers, using these hypothetical costs savings for each of the 5 scenarios based on the case study used for each scenario.

For each of the 162 service users who received REACH during 2013, a determination was made by the relevant REACH team of which scenario it was felt the service user came under at the conclusion of REACH (e.g. did REACH facilitate an earlier discharge home). The hypothetical costs savings for each scenario, from the case study, was applied to the number of 2013 service users considered to fall within that scenario.

Appendix 12 illustrates the resulting hypothetical savings for one year - £1,524,503 - for the clients who received REACH during 2013.The largest projected saving is in relation to the scenario of minimisation of home care requirements, i.e. less or none, compared with the projected outcome had REACH not been available. Of the 162 service users receiving REACH in 2013, the outcome for 118 (73%) of them were projected as having a minimisation of the need for home care following REACH. The

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hypothetical saving in home care over 1 year (net of the cost of REACH) for these

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118 service users was £1,234,169, equivalent to 58,769 home care hours (assuming £21 per hour).

From a cost benefit perspective, the total hypothetical £1.524m saving for one calendar year could in theory be compared with the £431,139 actual expenditure of the REACH projects for 2013/14 (staffing, equipment and office supply costs), i.e. the REACH pilots have arguably paid for themselves from a cost benefit perspective. Research undertaken by York University illustrated a comparable outcome with the long term cost savings for an individual. The overall social care cost reduced with rehab and enablement even when the initial rehab and enablement service cost are factored in, versus a comparison group who did not participate in an rehab and enablement programme.

Of course the reality is that this hypothetical ‘saving’ would be unlikely to become a budget saving for public agencies – due to the current demand and projected increase in future demand for services it is unlikely that the spend would be less. However, the capacity for savings against those service users that can benefit from rehabilitation and rehab and enablement allows public agencies to redirect those savings, giving the scope to meet increasing demand and address the needs of more people with the same resources.

Looking forward, while the REACH pilots have delivered ‘savings’ through the incorporation of both rehabilitation (restoring skills to clients due to illness or injury) and home care rehab and enablement (improving independence for clients by learning or re-learning skills necessary to maintain independent daily living), each of these approach can separately deliver savings.

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Conclusion and Recommendations

The Aims of the Aberdeenshire Joint Project were:-



To determine service users’ perceptions of rehab and enablement. To determine the impact of rehab and enablement on home care capacity.

Rehab and enablement services and/or an rehab and enablement ethos are key to delivering quality client centred services. The researched feedback from service users and their carers identifies, clearly, a value in support to increase independence, confidence and engagement. This increase in independence, confidence and engagement is critical as our population ages alongside a potential reduction in those of working age. The requirement is to ensure services deliver client centred, cost effective, sustainable services. Rehab and enablement as part of the Rehabilitation continuum can contribute to this.

The evaluation identifies the following areas of learning:

The REACH intervention enabled service users to meet their outcomes in terms of promoting and improving their independence and confidence

The most keenly felt and positive aspect of the REACH pilots was the value placed on the impact of the intervention by service users in terms of improvements to their independence and confidence.

The success of the intervention was felt to be due to a large degree to the method of delivery and the interplay of three components;

o Time – the capacity for care staff to provide the time required to support intensive rehab and enablement interventions, the flexibility and speed by which interventions could be arranged between different professions and care plans altered accordingly to meet service users’ capacity,

o Targeting – the targeted nature of intensive intervention over a matter of days or weeks for those service users assessed as capable of benefiting.

o Teamwork – the close communication between carers and the key professions of Occupational Therapy, Physiotherapy and District Nursing, ensured flexibility and timely response of services, tailored to the changing ability and capacity of the service user on a day to day basis.

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Insufficient information/promotion of the service made a contribution to a low referral rate.

Engagement and education with service users and families is essential for promoting cultural change from a ‘doing for’ approach to an ethos of enabling service users to ‘doing for themselves’.

The same is true for staff, where cultural change is required to foster an enabling ethos across all health and social care staff.

The above learning points identify a need for comprehensive information for service users and partner agencies to be widely available, in a variety of formats, and to ensure that time is spent explaining the intervention to service users and their informal carers.

The model used in REACH was primarily a discharge one, based on an opt in model ; to widen the use of the service an intake model is recommended so that all service users, that would potentially benefit from rehab and enablement, are considered for their rehabilitation and enablement potential in the first instance..

The eligibility criteria should be inclusive rather than excluding certain groups, to ensure a person-centred approach that maximises a service user’s potential for independence.

The single point of access for REACH is identified as effective and should be continued for a future pathway.

REACH predominately focused on new service users with no previous care package. It is recommend that a future rehab and enablement pathway is considered for service users at the point of reassessment or review, as well as at the initial assessment stage,

A lead practitioner for each intervention is effective for providing a single, person-centred assessment, drawing on other professional’s expertise as required.

Outcome based goal setting, in collaboration with service users, is critical to the success of any model of rehabilitation and enablement .

20% of service users commented that they didn’t feel included in goal setting. The paperwork and skills of staff implementing rehab and enablement need to ensure that the process is person centred and that outcomes are understood and agreed by all.

In the evaluation occupational therapists led the intervention due to their skills in functional assessment and goal setting. While these skills are central to the rehab and enablement approach, in the new pathway, consideration will need to be given to other team members developing these skills due to the anticipated demand on the service.

The health and social work integrated team and service approach was a strength of REACH and joint service delivery and responsibility is recommended.

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Identified as a strength of REACH is more effective engagement with home carers as part of the multi-disciplinary team. There needs to be consideration of how to include home carers as valued team members in the new rehab and enablement pathway.

The need for timely reviews was highlighted, to revise agreed outcomes and ensure that further steps are planned, where a service user has achieved progress in meeting those outcomes.

There is no reference to the use of assistive technology in the evaluation, although telecare packages were used for a number of clients as part of the intervention delivered. The scope of the Telecare and Telehealthcare service to play an integral role in a rehab and enablement approach should be explored and maximised.

One of the challenges identified, was that there were blockages in the system for some service users at the end of REACH when they required to move onto another type of service.

To address the risk of blockages rehab and enablement pathway needs to be integrated into the whole system to ensure a seamless service delivery for the service user.

Effective links should be developed with third sector organisations to ensure that service users are supported with meeting outcomes to engage in social opportunities through community and natural supports.

Training for REACH staff involved a combination of work shadowing and mixed sessions of practice and theory with occupational staff. While training has primarily focused on homecare staff this should be available to all staff to ingrain an rehab and enablement ethos in the health and social care culture.

A robust and effective training programme, that contains both, theory and practice, is required to equip staff with the skills to communicate, promote, assess and deliver a rehab and enablement service.

The majority of service users of REACH were not in receipt of a care package prior to the service intervention. This presented a methodological challenge in evaluating the impact of the REACH service on homecare provision.

The method used to address the above point, the projected cost benefit analysis, showed a reduction in care provision compared to a hypothetical outcome, resulting in potentially significant savings in relation to those individuals receiving support through REACH.

The findings from this evaluation and other research evidence that there remains a positive case for rehab and enablement due to its success in meeting valued outcomes for service users and the reduction in a homecare service, and subsequent freeing up of resources to redirect elsewhere that this could achieve.

Aberdeenshire’s multi-disciplinary, multi-agency approach has prepared teams for an integrated team model.

From the above learning the following recommendations for action are put forward to the Health and Social Care Partnership –

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The REACH pilots had stand alone teams however:

A rehab and enablement pathway requires to be developed that includes all professions in the health and social care teams and to ensure the pathway is embedded within integrated practice.

Continuation of training for all home carers and practitioners on rehab and enablement through e-learning, induction and further training of all CTC’s, LAC’s and Care Managers

Goal Setting is adopted by all MDT’s involving the client and/or carers. This will involve developing training on goal setting/utilising existing goal setting training delivered to all MDT’s as part of planning for integration.

Relevant information developed and used to inform the wider staff group and local community. This requires development of information in all formats ie. written, web based etc

The role of homecare service as part of an enabling structure considering the flexibility of service delivery required for rehab and

Move from a predominately discharge model to an inclusive mainstream intake model i.e. Service users in need of assessment or at service review, are functionally assessed and considered for rehab and enablement intervention as appropriate.

Consideration that commissioning is essentially a task focused process so engagement with those commissioning services to determine how an enabling ethos and specific rehab and enablement programmes can be integral to commissioning.

Improving the relationships and communication links between the home carers and the MDT considering how home carers can be part of MDT’s

Engagement with third sector to consider co-production and involvement in pathways

Explore the implications of the local authority charging policy

Paperwork review in line with integration and pathway work

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Below is the Action plan, suggested timescales and some provisional detail and resource implications. Whilst this can be led from within existing management structures in the partner agencies project management capacity will be required. Discussion and proposals fully costed would require to be presented the Older Peoples Strategic Outcomes Group (OPSOG).

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Action Plan

Action Detail Timescale Lead/OthersDevelop rehab and enablement pathway

Workshop to look at pathways, integration, and exit strategy for those with ongoing care needs

November 2014 Social Work Manager and AHP Lead

Continuous improvement and Learning and Development from partner organisations

REACH leads and project support.

Training for all home carers and practitioners.

Review what has been developed

Training needs analysis to identify gaps, create training plan and develop training.

Roll out via induction/e-learning/face to face sessions

Review and identify gaps Oct 2014

January 2015

Further training March 2015

Training team with additional project support.

Explore other training partnerships.

Develop goal setting training to direct service users interventions.

Utilise existing goal setting packages. Develop further training as required as integral to integration.

Roll out goal setting.

February 2015

March 2015

Integration team

Creation of a public information strategy for rehab and enablement.

Review current paper based information

Develop information in variety of formats

March 2015 Communication team/project support.

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Develop flexibility within care at home services to be able to provide a responsive service within the rehab and enablement pathway.

Review of current home care rostering structure and implementation of a new structure.

Links to training action plan to ensure that home carers and other care providers have the skills to provide an enabling service.

Identify the role of private providers and personal assistants (SDS) and how they will be included in the pathway.

March 2015 Social work manager for rehab and enablement

Project support/commissioning team/SDS team.

Home care managers.

Move from a predominately discharge model to an inclusive mainstream intake model i.e. service users requiring assessment or at service review are functionally assessed and considered for rehab and enablement

The development of a screening and allocation process where a service user has rapid access to an assessment by one lead professional.

Links to pathway development, goal setting and integration.

March 2015 Social Work Manager-Rehab and Enablement/AHP Lead.

Integration team/GP leads for integration/project support.

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Paperwork review in line with integration and pathway work

Review of current paperwork and further development if necessary. Consider how the paperwork will link into existing systems e.g CareFirst/SDS.

March 2015 Social work manager-rehab and enablement/AHP lead.

Project support/ social work manager-older people and physical disabilities/SDS team/business services.

Consideration that commissioning is essentially a task focused process so engagement with commissioning services to embed an enabling approach, an outcomes focussed commissioning model.

Training December 2015 Social work manager for older people and physical disabilities.

Commissioning team

Improving the relationships and communication links between the home carers and the wider team.

Consider how homecarers can play a more integral role with the wider team.

March 2015 Home care managers/project support.

CHP area managers.

Integration team.

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APPENDIX 1

Rehabilitation and Enablement Process

What it is

Rehabilitation and Enablement (R&E) interventions comprise the use of focused, intensive intervention and self management to prevent avoidable admission to hospital, to facilitate early supported discharge and to restore and optimise an individual’s autonomy in key aspects of daily living. Enablement is a time limited intervention that supports the person and/or carer to achieve set goals to support the maximising of independence and community involvement whilst reducing reliance on traditional forms of social care support. All involved would be working towards supported self management, linked with any anticipatory care plan in place.

Eligibility criteria

Referred to service from listed referrers following screening, predominately but not exclusively over 65 years and who have the potential to achieve identified enablement goals within designated time frame. Participation in enablement would not exclude service users from receiving other interventions e.g. Community rehabilitation or out-patient Physiotherapy. The service will be accessible to all those people who meet the initial criteria, including those with complex needs, mental illness and dementia.

Process

The multi-disciplinary staff (team) will consist of health and social work Occupational Therapists, Home Care staff, Care Managers, District and Ward Nurses, Physiotherapists and other disciplines will input as required.

Each enablement staff group will have a lead professional who will be accountable for screening and accepting or rejecting referrals.

Using a single point of access, referrals will be accepted initially from hospitals, GPs, Occupational Therapists, both health and social work, Ward and District Nurses, Care Managers, AHPs, and the Home Care service.

The service user must be medically fit enough to participate, have the potential to achieve identified goals within a 6-8 week period. They must demonstrate motivation to become or remain independent at home. Goal setting is therefore specific to that person and what they wish to achieve.

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An allocated key worker will assess using the SSA/designated paperwork and set specific goals in conjunction with the person and their family/carer.

These will be time limited, outcome focussed and delivered within the person’s own.

Home within the community where they live.

This period of enablement will normally be delivered within a six week period but could be extended for a further time limited period if necessary and would be free at the point of delivery.

Agreement will be reached with the person as to how the goals will be measured.

There will be agreed milestones within the average six week timescale.

Progress will be regularly reviewed against measurable outcomes.

At the end of this period, the person will be discharged from the service or transferred to another appropriate service.

The objective is to rehabilitate individuals through an enabling approach, delivered in an integrated way.

The lead professional can be an Occupational Therapist, Physiotherapist, Care Manager, or Nurse and they will coordinated the intervention of the service user, having consideration of the primary needs of the service user, the particular skills of each staff member and ensuring consistency and continuity of care. The team will build on the existing core skills and competencies of practitioners in assessment, goal setting, care planning, coordination and review. A key worker will be allocated to individual service users.

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Types of Support

People will be encouraged to:

make best use of their abilities and potential for improved autonomy regain skills that have been temporarily lost due to illness, hospitalisation or

disability Improve self-confidence in their daily living skills and managing their own

health.

Carers and families will be involved in order to gain their support for setting and reaching goals and milestones. Daily and weekly recordings will evidence progress towards and/or issues affecting the individual’s goals. Once the agreed period of enablement has concluded, the key worker will formally discharge the person by closing the case, transferring the case to another service and/or signposting the client to preventative community activities/facilities.

Evaluating the process

Outcome Evaluation is ‘A systematic process of gathering, interpreting, and reporting information to identify and illustrate the end ‘result’ of services (Stanton et al, 1997).

What are the primary steps to evaluate outcomes?

Identify what might change over the course of intervention, that is, potential outcomes.

Choose an assessment method to gather information about potential outcomes. .

With each person, set individual person-centered goals to achieve during intervention.

After a period of intervention, identify and document the person’s outcomes i.e. goal achieved or not achieved.

Data Sources

Qualitative data - this is to be collected via prior well being and final patient satisfaction questionnaire, with quantative data coming via home care contact hours before and after intervention.

Shona Strachan/Lesley Mackenzie July 2011 (V6)

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REABLEMENT PLAN - Example Form APPENDIX 2

CLIENT NAME Mrs A N Other GOAL NO. 6 Personal Hygiene

DATE CURRENT ABILITY SIGNATURE/DESIG

1st October 2009

Goal 6. Unable to wash lower body without assistance

GOAL No. ACTION TARGET DATE

6 For client to be able to wash herself independently and to be able to put on pants and stockings

Work alongside client giving encouragement and practical assistance with personal care tasks

Encourage client to wash body as low as is possible to maintain/improve mobility

Discuss with client whether long handled sponge may assist with washing – if so assist to use correctly once purchased

Advise and reinforce on technique using helping hand to put on underwear more easily without bending down

Encourage use of stocking aid to assist with stockings. Once mobility improves encourage easier technique using stool/chair to bring foot closer.

Week beg 10th November 2009

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DAILY PROGRESS RECORD

DATE DAILY PROGRESS SIGNATURE/DESIG

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APPENDIX 3

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Enablement APPENDIX 4

Below are some key points from today’s presentation

Definition of Enablement:-

Enablement is a time limited intervention that supports the person and/or carer to achieve set goals to support the maximising of independence and community involvement whilst reducing reliance on traditional forms of social care support.

Definition of Rehabilitation:-

The process of restoration of skills and function of a person who has had an illness or injury so has to regain maximum independence, self-sufficiency and function in as normal or near normal manner as possible.

Why now?

Enablement is relevant because it moves from a task orientated approach where service users receive a package of care, often for long periods with little or no reduction in the level of care. Enablement moves to a needs led approach focused on service users’ strengths and abilities, where they, and their families, play a key role in the care accepted. By actively involving service users with the aim to increase their independence a culture of ‘work with’ rather than ‘do to or for’ is required. It is about maximising service users long term independence and quality of life. And also appropriately minimising ongoing support required and thereby minimising the whole life cost of care.

Enablement Vision:-

No community care waiting lists

No delayed discharges

Clear understanding of those who are eligible

Goal setting and care plan the same day for every service user

Clearly defined roles for staff involved in delivering enablement

Accurate and up to date data

Competent use of relevant documentation

Competent handovers

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Key Elements of Enablement:-

Working together to achieve a positive and sustainable change

Forming a contract with service user, carer and staff

Assessing for improved outcomes with individual service users

Formulating the package of care around goal setting, reviewing outcomes and planning further intervention as required

Including unpaid carers in the process

Time limited enablement programme averaging 6 weeks

Increasing the skill base for staff and providing additional training for staff

Who will be involved:-

A mix of social care staff and health staff – Home Care; Home Care Supervisors; Home Care Managers; Occupational Therapists both health and social work; Physiotherapists; Nurses both community and hospital.

Goal Setting:-

Following assessment a service user will be involved in setting their goals. This will then be recorded on the paperwork attached. Goals need to be SMART – Specific, Measurable, Attainable, Relevant and Timely. The care plan will guide how goals will be achieved with specific instructions. Daily and weekly progress reports will be completed to monitor progress.

Enablement terminology:-

Prompting- Physical – guiding hand

Verbal – instruction, direction to follow e.g. “Now get the milk from the fridge”

Visual – gesture etc

Assistance- To provide physical help with specific aspects of a task

Supervision- To observe/oversee execution of task

Cueing- Subtle hinting

Shona Strachan/Sandra Scott 2.6.11

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APPENDIX 5

REHABILITATION AND ENABLEMENT IN ABERDEENSHIRE FOR CARE AT HOME (REACH): AN EVALUATION

KEY FINDINGS

1. STUDY

A combination of process evaluation and outcome evaluation was used in the study. The former examined issues of implementation while the latter focused upon impact and change. A range of ‘mixed methods’ was used including interviews, questionnaires (clients and informal carers) and focus groups (agency staff). Fieldwork was carried out between December 2012 and January 2014

2. FINDINGS: CLIENTS

Biography - The sample comprised 21 women (66%) and 11 men (34%) who ranged in age from 43 years to 97 years. Four-fifths were aged 72 years or older (78%). Around half were widowed (47%, n=15) and a quarter married (25%, n=8). More than two-thirds lived alone (71%, N=22), whilst the remainder lived with their partners (29%, n=9). Use of REACH Clients use of REACH ranged from two to 12 weeks. In terms of ‘discharge’, three-quarters of participants reported that they had left REACH in an agreed and planned way. Usefulness of REACH Clients came to know about REACH through two main sources; health care professionals and social work staff. GPs were a third commonly reported source of information. The most reported reasons for accepting support from REACH was that the service was available at a time of immediate need, followed by the attraction of the practical supports REACH could provide. Four-fifths of participants reported that access to REACH was easy. The majority felt that their initial assessment had been thorough and accurate. A fifth disagreed. Three-quarters of participants considered that their goals had been met at the point at which they left REACH. A fifth disagreed. With respect to the former, participants made reference to five main areas of achievement: the carrying out of domestic tasks, the ability to perform personal care tasks, the ability to resume caring duties on behalf of someone else, becoming physically mobile again and a general feeling of being independent, confident and ‘in control’. With respect to the latter, participants reported being unaware of goals having been agreed in the first place or feeling that needs remained outstanding.

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3. FINDINGS: UNPAID CARERS

Biography - The sample comprised a group of 13 middle-aged to older people, the vast majority of whom were women (female, 85%, n=11, male, 15%, n=2). They ranged in age from 42 years to 80 years with a mean average age of 60 years. Around a half looked after their mothers and a third looked after their spouse, although a variety of other caring relationships were found. Caring Role 12 carers provided help in dealing with care services and benefits, practical supports, company, offered trips outside the home and generally ‘kept an eye’ on the person looked after. Just over half of carers oversaw the taking of medication whilst two-thirds provided personal care. Half of the carers reported spending up to 19 hours each week providing support. The majority had done so for 5 years or more.Challenge of Caring Carers took on the role through a combination of willingness, duty and a lack of other support being available. Three-quarters of carers reported that their lives had been adversely affected by taking on the role. A loss of leisure time was commonly reported. For more than half, caring impacted negatively upon their health. Views of REACH Around a third of carers felt that the person they looked after had gained or re-gained full independence having experienced REACH. Around a quarter reported that REACH had made no difference to the independence of the person looked after. Around two-thirds of carers reported that those whom they looked after had grown in confidence as a result of experiencing the REACH programme. A third disagreed. The vast majority of carers could find nothing wrong with REACH. Likewise, the vast majority could not think of ways that the service might be made better.

4. FINDINGS: AGENCY STAFF

Problem Identification Staff identified three distinctive features of REACH: its rationale of enablement; its methods in terms of time allocation, targeting of clients and team working; and its outcomes in terms of promoting quality of life and preventing unsuccessful hospital discharges. REACH was regarded as justified as it addressed the unsustainable, traditional model of homecare.

Service Design Demand for REACH services was low due to the size of teams, initial uncertainty about roles and a lack of advance planning. Problems were regarded as transitional and were overcome. The type of support offered, enablement, was not well understood by clients, families and other agencies. Engagement with informal carers had both negative and positive outcomes. Risk became an issue. Multi-agency working led to information sharing, mutual respect and better assessment of need. The resource allocated to REACH was regarded as adequate but there were

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problems recruiting occupational therapists, physiotherapists and homecare staff. Staff training was ‘on the job’ rather than standardised.

Service Usefulness REACH worked with the ‘right’ types of client but ‘coverage’ was low. Access was limited by geography and a lack of advertising but improved once more GPs engaged. Staff identified seven main strengths of REACH: timeliness, enablement philosophy, reduction in need for long-term support, secondary mental health benefits, support for families, good processes and awareness of its own limitations. Staff indentified four negative factors associated with REACH : types of client, size of

REACH teams, throughput and training. Staff identified eight ways of improving REACH: improve the referral process, administrative support, more occupational therapists, flexible shift patterns, avoid follow-up visits, more team working, more training of home care staff and the recruitment of more home carers.

5. CONCLUSION

REACH was evaluated by three of its ‘key players’ (clients, unpaid carers and agency staff) as a worthwhile initiative that offered a distinctive and welcome way of providing care to older people. Its underlying philosophy was sound and in tune with wider movements (e.g. self directed support, personalised care) to empower clients and challenge existing orthodoxies of care. Dr John G Love, Robert Gordon University, Aberdeen June 2014

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APPENDIX 6

Unit cost 2013

Unit cost = total REACH staffing cost (salaries) / total clients accepted through REACH.

Inverurie Staffing costs 13/14 £127,894.80

Clients through Reach 2013 72

Unit cost of REACH £1776.31

Peterhead Staffing costs 13/14 £144,428.79



Turriff Staffing costs 13/14 £64,822.41



Actual REACH costs for each case study (projected for 1 yr and inclusive of care where post REACH care involved, and inclusive of any equipment used as part of the Reach intervention)

Scenario 1 (Turriff) - £5,971.10

Scenario 2 (Peterhead) - £1,038.45

Scenario 3 (Inverurie) – £11,542.38

Scenario 4 (Peterhead) - £5,775.28

Scenario 6 (Inverurie) - £2065.35

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APPENDIX 7

Scenario 1

(Reduction in Home Care hours)

REACH input from December 2011 to February 2012

78 year old lady, had been in hospital following infection and reduced kidney function. Walks with four wheeled walker or walking stick in confined spaces.

Had usual in-patient rehab in community hospital.

OT assessment and practise in self-care, transfers, functional mobility and kitchen tasks (making hot drink and heating meal in microwave). OT found the service user required very little input with the above and was surprised that patient stated “the home carer does that for me at home”.

Following discussion with patient, in which she appeared keen to do more for herself at home, REACH plan was formulated for discharge.

Prior to admission, service user had five home care visits per day:

1. Early morning, to detach overnight catheter bag.2. Morning, to assist with personal care and weekly bath, to accompany down

stairs, make breakfast and give tablets.3. Lunch time, to heat meal and give tablets.4. Tea time, as above.5. Bed-time, to accompany upstairs, get ready for bed and attach overnight

catheter bag.

It was assessed that SJ could not attach or detach her overnight bag due to reduced strength in her fingers.

REACH goals started with increasing independence in basic washing and dressing, but, over time, others were added, including:

SJ to get out of bed and wash and dress once her overnight bag was detached, and not wait for home care to come back and assist with washing and dressing.

SJ to make own breakfast, take medication from blister pack in kitchen and tidy up afterwards.

SJ to heat own meal at lunch and tea-time and take medication without waiting for Home Carer to do so.

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Outcome:

By week two, was managing washing and dressing with supervision only, (apart from once a week bath with which assistance was required to operate powered bath lift) and taking medication from blister pack with supervision.

By week three, was managing to wash and dress without REACH carer, and was encouraged to take her medication at the correct time without waiting for REACH carer to arrive.

By week four, no longer required second morning visit to facilitate washing and dressing.

By week five, gradual phasing out of lunch and tea visits resulted in REACH input being able to be discontinued in week six.

Handover to Mainstream Home Care was possible, with the requirement for only two brief visits, early morning and bed-time to attach, detach (and empty) catheter overnight bag, and weekly visit for bath.

It can be assumed that, without REACH, this service user would have been discharged from hospital to the same level of home care (5 visits per day) as the pre admission level received.

Scenario 1

Reduction in Home Care input

REACH Care PackageAnnual Value

Turriff Reach Unit cost 2400.83

Post Reach 2 x 15min daily home care (£21ph) 3832.50

Post Reach 1 x weekly bath visit (assume 1 hr) 1092.00

Total Annual Value with REACH intervention (yr 1) 7325.33

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Actual REACH staff input costs on this service user. Hours Hourly rate

OT/Team lead 4.5 21.64 97.38

Hospital OT 1.5 16.81 25.22

Physio 0 16.81 0

Carers 44 21 924

Nurse 0 15.26 0

TOTAL 1046.60

Post REACH 1 x weekly bath visit (assume 1hr) 1092.00

Post REACH 2 x 15min daily home care 3832.50


Alternative Care packageAnnual Value

early morning visit (assume 15min) all based 1,916.25

morning visit (assume 30 mins)on £21ph 3,832.50

lunchtime visit (assume 15 mins) cost 1,916.25

teatime visit (assume 15 mins) 1,916.25

bedtime visit (assume 15 mins) 1,916.25

weekly bath (assume 1 hr) 1092.00

Total Annual Value of Alternate 12,589.50

Cost saving between actual REACH cost and alternative (p.a) 6,618.41

The REACH cost of £5971.10 over one calendar year (inclusive of 2 x daily and 1 x weekly home care visits post REACH) represents a saving of £6,618.41 over 1 year in comparison to the alternative (£12,589.50 for 1 year), had the service user returned home to the same level of home care provided prior to admission to hospital. Assuming the service user remained stable at that level of care, that annual saving could be multiplied across several years.

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APPENDIX 8

Scenario 2 (2012)

(Minimisation of Home Care)

Service user who has no paid homecare before REACH and no paid homecare after, but probably would have done without REACH.

Service user- 78yr old woman living alone in a two storey house in a rural location.

Medical history- Right total hip replacement (11/04/12 at ARI), kidney disease, past bowel surgery, and neck surgery following a road traffic accident when young which also resulted in a very abnormal gait, and limited use of her left arm.

Referral- Was admitted to Peterhead community hospital (27/06/12- 05/07/12) from ARI following hip surgery. Referral to REACH was for support with meal management and personal care activities. 3 x visits daily requested by hospital ward staff, Community nursing staff had also stated that they felt she should receive a full care package as in their view she was not managing at home prior to admission.

Clients own goals- To be independent with personal care, independent with meal management, and to be safe and confident to go outside herself shopping and visiting friends. (All goals achieved).

Following REACH assessment it was agreed with the client that REACH would commence with 2x daily visits, as this would meet her needs and support her to work on her goals. These two visits continued throughout the 8 weeks of input and different activities were supported at different times during these visits in line with the lady’s goals.

Onward referral was for RVS requesting a companion and shopping service.

Total input from the REACH team:-

REACH Team Lead (OT) = 4hrsHospital OT= 30 mins Physiotherapist = 2hrCarer = 42 hr 40minNurse= 1hour

Likely scenario had REACH not been provided

It can be reasonably assumed that this lady would have received paid homecare services for 30mins 3 x daily permanently if REACH had not been involved. REACH were able to increase her ability and confidence, which in turn showed both her, and other people that she could indeed manage at home independently.

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Scenario 2

No paid home care before and prevention of paid home care after REACH

REACH Care Package

Peterhead REACH Unit cost 2292.52

Actual REACH staff input costs on this client Hours Hourly rate

OT/Team lead 4 21.64 86.56

Hospital OT 0.5 16.81 8.405

Physio 2 16.81 33.62

Carer 42.6 21 894.6

Nurse 1 15.26 15.26

TOTAL 1038.45


Carer 30mins 3 x daily (£21 ph) 11,497.50

six monthly needs assessment review cost?

Total Annual Value of Alternative 11,497.50


The REACH cost of £1,038.45 represents a projected annual saving of £10,459.06 in comparison to the alternative cost (£11,497.50 for 1 year), had the service user returned home to the 3 x daily home care visits requested by the hospital ward staff. Assuming the service user remained stable at that level of care, that annual saving could be multiplied across several years.

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APPENDIX 9

Scenario 3

(Avoidance of hospital admission)

82 year old woman living alone in a ground floor property, accessed by steps, in a town.

Past medical history

Bilateral hip replacements. 2 falls in 2 weeks leading to decreased mobility, degenerative eye condition. During our visits it became apparent there were cognitive issues.

Referral

Via GP and rapid response. Lady had been in hospital and referral had been made for SWOT follow up on discharge. No mention of care being required. GP felt that urgent care was required or readmission likely.

Sevice User’s Goals

To be able to look after herself, cook and get around her house. Her main goal was to be able to visit son for Christmas.

REACH visited 4 x day initially following OT assessment.

During her period on REACH it became evident that she was not coping with self medicating. Numerous strategies/ aids were trialled and GP altered timings etc. As she was unable to be independent she required medication management 4 x daily. She achieved all her goals except the medication visits and prompts/ check re meals.

Onwards referrals

RVS – befriending, re ref for restart of 2 x week. Medication management visits 4 x daily. CAS wristband. Advise re PoA. Request to GP for OAP referral. Key safe.

Input

Lead 8 hrsOT 7 ½ hrs direct, 3 hrs indirect (10.5 total)Physio 7 hrsCarers 152 hrsNurse aware of 3 visits

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Time on REACH

12 weeks total including 2 weeks while she was at sons/ hospital and 2 weeks awaiting mainstream pick up. 8 weeks of REACH input.

Equipment

Trolley, perch stool, kettle tipper, zimmer, bed lever, commode

Without REACH, it is envisaged that this lady would likely have been re-admitted to a community hospital for a minimum stay of 3 weeks.

Scenario 3 Avoidance of hospital admission

REACH Care Package

Inverurie REACH Unit Cost 1776.31

Equipment:

Perch stool, commode, zimmer 71.99

bed lever, trolley, kettle tipper 58.25

Delivery/on costs for equipment 30

Post REACH 4 x medicine mgmt visits per day (assume 15min each) 7665

Post REACH key safe + installation cost 50

Post REACH Community Alarm wristband 2.5

Total unit cost and Equipment and yr 1 costs 9654.05

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Actual REACH staff input costs on this sevice user. Hours Hourly rate

Team lead 8 20.4 163.2

OT 10.5 16.81 176.505

Physio 7 16.81 117.67

Carer 152 21 3192

Nurse 1 15.26 15.26

Total 3664.64

Equipment (as above) 160.24

Post REACH 4 x medicine mgmt visits per day (assume 15min each) 7665

Post REACH key safe installation cost 50.00

Post REACH Community Alarm wristband 2.50

Total staff costs and equipment and yr 1 costs 11,542.38

Alternative Care package

3 weeks (min) stay in community hospital at £279 total bed day cost

Post REACH 4 x medicine mgmt visits per day (assume 15min each)

Post REACH key safe installation cost

Post REACH Community Alarm wristband

Total cost of alternative for yr 1 13,576.50


The REACH cost of £11,542.38, although arguably higher than the cost of the average REACH intervention, still represents a saving of £2,034.13 in comparison to the alternative cost of £13,576.50 for the projected 3 week hospital stay that this service user was otherwise anticipated to result in.

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APPENDIX 10

Scenario 4 (2014)

(Avoidance of residential care)

Service user- A 78 year old gentleman that was placed in a nursing home (5/9/13) when his wife was taken ill- His wife subsequently passed away. This gentleman remained in the nursing home for 26 weeks at a cost of £583.11 (Figure from Care manager) per week.

Medical history- This gentleman suffered a CVA several years ago that left him with a Left sided weakness that includes a drop foot, and significant reduction in use of his Left hand.

This gentleman was not happy in residential care, and it was felt by the care manager that with some rehabilitation this gentleman may be able to be supported within his home environment.

Service user’s goals-

1) To be independent with meal management (Goal achieved)2) To be independent with personal care (Goal achieved)

Following assessment it was agreed that REACH carers would visit three times daily. This continued for 1 week, and then reduced to 2x visits daily for a further 3 weeks and then a further week at 1x daily visit. At this point REACH would have completed their input However mainstream ongoing input had been requested for 1xdaily 30 min visit to ensure that orthotic was correctly positioned for safety, and to support with a shower. (1 further week of input undertaken until care was found.)

Forward referral was to RVS for support with collection of medication, taking to bank, and companion type service.

Basic REACH input-

REACH Lead (OT)- 5hrsNurse- 1hrHospital OT- 1.30hrsCarers- 24.40hrs

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It can be reasonably assumed that this gentleman would have either remained in nursing care or returned home with 3x visits daily permanently if the REACH service had not been available to work intensively with him.

If the decision to get this gentleman home without REACH input had been made, it is felt that he would have required 3xdaily visits (This was confirmed by the care manager) due to lack of confidence and reduction in his ability due to a multitude of reasons.

Scenario 4

Avoidance of residential care

REACH Care PackageAnnual Value

Peterhead REACH Unit cost 2292.52

Post REACH 1 x 30min daily home care (£21ph) 3832.50

Total Annual Value with Reach intervention (yr 1) 6125.02

Actual REACH staff input costs on this client Hours Hourly rate

OT/Team lead 5 21.64 108.2

Hospital OT 1.5 16.81 25.22

Physio 0 16.81 0

Carers 24.6 21 516.6

Nurse 1 15.26 15.26

TOTAL 665.28

Post REACH 1 x 30min daily home care 5110.00


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1. Previous residential home cost 583.11 pw 30,321.72

2. Fee Rate for Aberdeenshire care homes (£741pw 13/14) 38,532.00

3. At home with Carer 30mins 3 x daily 11,497.50

six monthly needs assessment review cost?


The REACH cost of £5,775.28 over 1 calendar year (inclusive of 1 x daily home care visit), represents a saving of £24,546.45 over 1 year, in comparison to the annual residential home costs of £30,321.72 that would have been incurred had the service user returned on a permanent basis to the care home he was in before admission to hospital.

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APPENDIX 11

Scenario 6

(Reduction in hospital stay)

A 75 year old woman living with her partner in a rural bungalow.

Past medical history

Revision of left total hip replacement with Girdlestone, cardiac arrest and stroke (RSW) all within 3 days.

Referral

Via MDT at community hospital where she was receiving rehab. View of Hospital OT that this was a reduction in hospital stay as opposed to delayed discharge as hospital would not have been confident to discharge patient to mainstream care as felt they would not cope – evidenced by fact that Reach carers had numerous contacts on a daily basis with the OT to maintain the patient at home.

Prior to medical conditions she was fully independent.

Service User’s Goals

To be independent in self care and then work on kitchen skills. As she progressed she added outdoor mobility and re accessing community groups.

REACH visited 2 x day initially following OT assessment.

Initially discharged using wheelchair and transferring with zimmer.

REACH progressed her quicker. No mainstream care available in area/ or for level of input required. If not home on REACH it was felt she would have been another 4 weeks in hospital/ or definite readmission.

The lady met all her goals and went beyond expectation and became mobile within her home on crutches.

Onwards referrals

CAS

SWOT – closomat and external ramp, Level Access shower

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Input

Lead 4 hrsOT 8 hrs direct 1 ½ hrs indirectPhysio 10 hrsCarers 59 hrsNurse aware of a few visits

Time on REACH

8 weeks. She was so determined to complete in 8 weeks.

Equipment

Perch stools, wheeled commode, bed lever, temp ramps, sock aid, handy bar, LH sponge, leg lifter, hand blocks, turning disc.

Scenario 6Reduction in Hospital Stay

REACH Care Package

Inverurie REACH Unit Cost 1776.31

Equipment:

Perch stool 18

wheeled commode 75

bed lever 26.99

temp ramps (165) turning disc (22.50) 187.5

sock aid, handy bar, LH sponge, leg lifter, hand blocks, 64.2

Delivery and on costs for equipment 30

Total unit cost and Equipment 2178

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Actual REACH staff input costs on this service user. Hours Hourly rate

Team lead 4 20.4 81.6

OT 9.5 16.81 159.695

Physio 10 16.81 168.1

Carer 59 21 1239

Nurse 1 15.26 15.26

Total 1663.66

Equipment (as above) 401.69

Total staff costs and equipment 2065.35


4 weeks in community hospital (@£279 total bed day rate for GP Acute) 7,812.00

Cost saving between actual REACH cost and alternative 5,746.66

The REACH cost of £2,065.35 represents a saving of £5,746.66 in comparison with the cost of the projected alternative likely scenario for this service user – a further 4 week stay in a community hospital at a cost of £7,812.00

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APPENDIX 12

REFERRALS

1.1 All

NUMBER OF REFERRALS Age RangeHealth Health Total SW Staff SW Staff Total Other Other Total Grand Total

REFERRAL SOURCE Female Male Female Male Female MaleUnder 65 15 13 28 14 13 27 3 1 4 5965-74 28 16 44 20 4 24 3 7 10 7875-84 65 29 94 45 22 67 12 9 21 18285 and Over 61 21 82 41 15 56 12 9 21 159Grand Total 169 79 248 120 54 174 30 26 56 478

1.2 2012NUMBER OF REFERRALS Age Range

Health Health Total SW Staff SW Staff Total Other Other Total Grand TotalREFERRAL SOURCE Female Male Female Male Female MaleUnder 65 4 5 9 7 8 15 2 2 2665-74 10 7 17 12 1 13 1 4 5 3575-84 23 14 37 20 10 30 6 5 11 7885 and Over 22 7 29 13 6 19 4 5 9 57Grand Total 59 33 92 52 25 77 13 14 27 196


Health Health Total SW Staff SW Staff Total Other Other Total Grand TotalREFERRAL SOURCE Female Male Female Male Female MaleUnder 65 6 6 12 7 4 11 1 1 2465-74 12 7 19 7 2 9 2 2 4 3275-84 33 9 42 21 9 30 5 3 8 8085 and Over 28 9 37 24 8 32 7 2 9 78Grand Total 79 31 110 59 23 82 15 7 22 214


Health Health Total SW Staff SW Staff Total Other Other Total Grand TotalREFERRAL SOURCE Female Male Female Male Female MaleUnder 65 5 2 7 1 1 1 1 965-74 6 2 8 1 1 2 1 1 1175-84 9 6 15 4 3 7 1 1 2 2485 and Over 11 5 16 4 1 5 1 2 3 24Grand Total 31 15 46 9 6 15 2 5 7 68

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1.5 InverurieNUMBER OF REFERRALS Age RangeREFERRAL SOURCE Health SW Staff Other Grand Total

Under 65 5 6 1 122012 5 52013 3 1 42014 2 1 3

65-74 13 9 4 262012 2 7 2 112013 10 2 2 142014 1 1

75-84 30 17 8 552012 6 10 2 182013 16 5 5 262014 8 2 1 11

85 and Over 36 22 13 712012 10 6 6 222013 18 15 5 382014 8 1 2 11

Grand Total 84 54 26 164

1.6 PeterheadNUMBER OF REFERRALS Age RangeREFERRAL SOURCE Health SW Staff Other Grand Total

Under 65 19 20 3 422012 7 10 2 192013 7 9 1 172014 5 1 6

65-74 23 11 4 382012 12 5 2 192013 6 4 1 112014 5 2 1 8

75-84 43 39 10 922012 22 14 6 422013 17 20 3 402014 4 5 1 10

85 and Over 28 23 4 552012 13 9 1 232013 11 13 3 272014 4 1 5


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1.7 Turriff

NUMBER OF REFERRALS Age RangeREFERRAL SOURCE Health SW Staff Other Grand Total

Under 65 4 1 52012 2 22013 2 1 3

65-74 8 4 2 142012 3 1 1 52013 3 3 1 72014 2 2

75-84 21 11 3 352012 9 6 3 182013 9 5 142014 3 3

85 and Over 18 11 4 332012 6 4 2 122013 8 4 1 132014 4 3 1 8


SERVICE USERS

2.0 All

NUMBER OF SERVICE USERSColumn Labels

TEAM INVERURIE PETERHEAD TURRIFF Grand Total65-74 19 19 11 49

Female 12 16 7 35Male 7 3 4 14

75-84 41 50 18 109Female 33 22 13 68Male 8 28 5 41

85 and Over 58 54 30 142Female 43 42 20 105Male 15 12 10 37

Under 65 9 32 3 44Female 7 14 3 24Male 2 18 20

Grand Total 127 155 62 344

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2012

2013



Female 3 8 1 12Male 2 3 5

75-84 10 25 7 42Female 9 11 5 25Male 1 14 2 17


Under 65 2 14 1 17Female 1 6 1 8Male 1 8 9


Column LabelsTEAM INVERURIE PETERHEAD TURRIFF Grand Total

65-74 13 6 4 23Female 8 5 3 16Male 5 1 1 7

75-84 26 20 9 55Female 20 10 7 37Male 6 10 2 18


Under 65 4 13 2 19Female 4 6 2 12Male 7 7


NUMBER OF SERVICE USERS

66

2014

SERVICE USERS NOW DECEASED

Number of Deceased Clients

Inverurie 20

Peterhead 19

Turriff 7

SERVICE USERS NOW DECEASED

Number of Deceased Clients

Inverurie 8

Peterhead 0

Turriff 3



Female 1 3 3 7Male 2 2

75-84 5 5 2 12Female 4 1 1 6Male 1 4 1 6


Under 65 3 5 8Female 2 2 4Male 1 3 4


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3.0 AVERAGE LENGTH OF SERVICE

AVERAGE LENGTH OF SERVICE.


Overall 6 6 6

2012 5 5 5

2013 6 7 6

2014 4 6 5

MODAL LENGTH OF SERVICE


Overall 3 2 6

2012 1 6 3

2013 3 1 6

2014 5 2 n/a

MAX/MIN LENGTH OF SERVICE


Overall 20/1 33/1 14/1

2012 20/1 12/1 14/1

2013 17/1 33/1 13/1

2014 6/3 19/1 8/2

N.B. n= 315 as remainder of service users are DNC or Ongoing

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INVERURIE

PETERHEAD

TURRIFF

NUMBER OF SERVICE USERSAGE RANGE

LENGTH OF STAY 65-74 75-84 85 and OverUnder 65Grand TotalOne to Two 4 5 6 2 17Three to Four 5 10 10 3 28Five to Six 3 8 18 29Seven to Eight 1 5 8 14Nine to Ten 3 2 7 1 13Eleven and Over 1 6 4 1 12Ongoing 1 2 1 2 6DNC 1 3 4 8Grand Total 19 41 58 9 127

NUMBER OF SERVICE USERSAGE RANGE

LENGTH OF STAY 65-74 75-84 85 and OverUnder 65Grand TotalOne to Two 7 19 18 4 48Three to Four 4 10 9 6 29Five to Six 9 8 8 25Seven to Eight 2 5 8 6 21Nine to Ten 3 3 3 2 11Eleven and Over 3 8 5 16Ongoing 3 1 1 5Grand Total 19 50 54 32 155

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NUMBER OF SERVICE USERS

AGE RANGELENGTH OF STAY 65-74 75-84 85 and OverUnder 65Grand TotalOne to Two 2 3 1 2 8Three to Four 1 5 4 10Five to Six 2 5 10 17Seven to Eight 1 3 6 10Nine to Ten 1 1 1 3Eleven and Over 1 3 4Ongoing 4 1 2 7DNC 3 3Grand Total 11 18 30 3 62

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Compiled by:

Shona Strachan, AHP Lead, Aberdeenshire CHP

Janine Howie, Acting Social Work Manager - Rehab and Enablement

Erika Skinner, Project Manager – Occupational Therapy

Morag Harris, Homecare Manager

Linda Wood, Homecare Manager

Ruth McMinn, Community Rehab Occupational Therapist / Project Lead Turriff

Susan Ray, Social Work Occupational Therapist / Project Lead Peterhead

Debbie Michie, Care Manager / Project Lead Inverurie

Catherine Jones, Information Officer / Social Work Aberdeenshire

Edited by:

Shona Strachan, AHP Lead, Aberdeenshire CHP

Janine Howie, Acting Social Work Manager - Rehab and Enablement

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