1. Lean Network NHS Lanarkshire & North Lanarkshire Council. Reshaping Older Peoples Rehabilitation. Background.Priority. Programme Charter.

2. How did we arrive here ? Pressures – Demand / Financial. Experience of joint working. Policy Drivers – Rehabilitation Framework. Appetite & recognition of the need for whole system redesign. Value base – service user. Issue with access/waits/repeat assessments.

3. Priority. Older Peoples Services. The Tsunami of growth ! Associated economic costs – care home placements/ home care/ acute beds Interdependence. Complex Care.

4. Goals. Redesign pathway from point of crisis, that promotes recovery, reduces disability, & independence and avoids unnecessary institutionalisation ( hospital/ care home ). Through redesign of community rehabilitation teams ( ESD/RR/Falls/Domi ) & older peoples (SW &PC) teams & diagnostic services (DHs,ACE)

5. Metrics Throughput/turnover Reduction acute admissions>65yrs = 20% reduction(breakdown per age band) Reduction A/E attendances >65 yrs = 20% reduction(breakdown per age band) Patient Safety = 90% D/C home 90 days. Service User Experience = Improve. Increase Community Rehabilitation = 40%

6. Metrics Effective delivery of reablement = 30% reduction packages of care. Care Home Admission = 0% direct from acute. Bed Capacity Reduction = 20% Access to Speciality Psychiatry = ? Increase clients managed at home = 40% Costs = 10% reduction.

7. Continuum Of Care Maximising Independence Short Stay Care Re-ablement Integrated community rehab teams Hospital Community Facilities Diagnostic Services