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Intermediate Care Scoping
- 1. Scoping
- 2. Online survey Hospital based discharge coordinators? Multiagency discharge hub? Linked to housing or third sector?
- 4. Supporting people to live the best life they can with their personal outcomes .....and that a reablement focus is maintained. What matters to you? Focussed on delayed discharge and moving towards a preventative approach. Having a holistic approach, rehab teams, OT’s and pharmacies all impact a person. Getting it ‘sized up’ to reflect the challenges we are going to face.
- 6. What would you like to learn from others? What would you like to share with others? Models of care Networking Evaluation Policy & Evidence Preventative/Early Intervention
- 7. What Intermediate Care & Reablement services do you provide?
- 8. Is there anything you would like help and support with?
Notas do Editor
- Scoping 31 partnerships. Consisted of online survey and conversation either face to face or phone call.
- Online survey considered the discharge arrangements from hospital. Most respondents have a discharge coordinator role. 18% have a multiagency hub with a further 18% in development. 10% had a discharge hub linked to housing and 20% linked to 3rd sector. This was an area of the conversation where Housing and third sector that people advised they would like support to engage with.
- getting it ‘sized up’ to reflect the challenges we are going to face set at a level that will meet the more complex levels of need. good outcomes are being achieved for service users and that a reablement focus is maintained. Safe effective care delivery Patient and staff satisfaction focussed on delayed discharge and moving towards a preventative approach delivering a service to where the person is in their safest place getting people out of a hospital environment and help support and promote independence Having a holistic approach, rehab teams, OT’s and pharmacies all impact a person Having multi-disciplinary approaches Supporting people to live the best life they can with their personal outcomes and prevent institutionalisation Keen to make changes in support services Great ambition around meeting peoples goals – maximising their ambitions and minimising their length of stay in hospitals. a person centred approach. Clients reaching full potential. Making sure the right services are available to the right people at the right time. Ensuring provision is effective as possible given the resources. Fully integrated pathways of care What matters to me is what matters to the patient. increased efficiency increase people’s independence Get people out as fast as possible not failing them Planning – ensure consistency to everyone accessing the service and get the best outcomes
- getting it ‘sized up’ to reflect the challenges we are going to face set at a level that will meet the more complex levels of need. good outcomes are being achieved for service users and that a reablement focus is maintained. Safe effective care delivery Patient and staff satisfaction focussed on delayed discharge and moving towards a preventative approach delivering a service to where the person is in their safest place getting people out of a hospital environment and help support and promote independence Having a holistic approach, rehab teams, OT’s and pharmacies all impact a person Having multi-disciplinary approaches Supporting people to live the best life they can with their personal outcomes and prevent institutionalisation Keen to make changes in support services Great ambition around meeting peoples goals – maximising their ambitions and minimising their length of stay in hospitals. a person centred approach. Clients reaching full potential. Making sure the right services are available to the right people at the right time. Ensuring provision is effective as possible given the resources. Fully integrated pathways of care What matters to me is what matters to the patient. increased efficiency increase people’s independence Get people out as fast as possible not failing them Planning – ensure consistency to everyone accessing the service and get the best outcomes
- Remote & Rural Bed-based intermediate care - striking balance between making it cost effective (as bed-based intermediate care is expensive) and a market for care that is challenging. Social Care intermediate care service is a challenge (but the most cost effective approach) as the providers in the market as not in the best position at the moment. Hospitals at home – scoping out clinical governance and ensuring it is wrap around. Has to be cost effective and robust (viable alternative option). Finding 24-hour wrap around social care is going to be a real challenge. In hospital, auxiliaries can provide care which is not clinical 24/7. Hospital at home needs to be staffed in an appropriate way to ensure sufficient care is provided. Social Care recruitment is already a challenge. Managing demand and throughout from ESD/PoA and Reablement i.e. moving on from teams together providers at the end of the reablement period. financial constraints Change management workforce skills development population demographics delayed discharges supporting/stopping hospital admissions build up community services and keep building finances Establishing a culture shift across expectations of independence services resources freed up consultants can be against intermediate care because it isn’t medical or specialised. Recruitment Stable source of ongoing funding geographical areas investing in the district nursing team to have 24/7 nursing care. Challenge as there is no framework in place to guide this proposal. Pressure to use Cordia budget for efficiency savings, but reablement can help deliver future savings. Make intermediate care comfortable for people, but it can become so comfortable that people don’t want to leave. Operational challenges including silo working, lack of full integration across services, resources not being where they need to be, particularly in shifting balance of care to the community. Challenges of an increasingly old and frail population. Dealing with public and political expectations of health and social care, integration, and cost / benefits. Resources. Financial constraint combined with a growing demand. Capacity for change How to ensure it’s used in early intervention and prevention need thriving & fully staffed private sector Financial constraints increasing population who are deprived and have a range of long term conditions
- Remote & Rural – Western Isles Paul is keen to hear from anyone around housing models of Intermediate Care or anyone who has overcome any of the challenges around remote and rural areas.