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Islington - Joint Services Reablement Team Mary Jamal Head of Disability and Intermediate Care.

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Presentation on theme: "Islington - Joint Services Reablement Team Mary Jamal Head of Disability and Intermediate Care."— Presentation transcript:

1 Islington - Joint Services Reablement Team Mary Jamal Head of Disability and Intermediate Care

2 Background Contracts with eight external providers An in house home care service specialising in users with dementia A small rapid response and enabling service delivered by an external agency (in operation since 2004) Monitoring All the contracts monitored with the exception of the home care team activity Based on a small sample size activity from the rapid response agency, there was evidence of 56% of clients had their home care hours reduced and 78% of clients discharged had no on going home care or a reduced package Budget spend Home Care budget was around 17% of the budget for Islington Adult Social Services Home care spend increased by 7% from the financial years 2005/6 (from 11.9 million to 12.7 million) Was predicted to increase by 4% 2006/7 (from 12.7 million to 13.2 million) Before Reablement…

3 Why set up a Reablement service? Fit with government policy The four key objectives of the White Paper Our Health, Our Care, Our Say: better prevention with earlier intervention more choice tackle inequality & improved access to community services people with long-term conditions supported to manage their conditions The National Service Framework for Older People: Standard 3 Intermediate Care: prevent unnecessary acute hospital admissions, support timely discharge and maximise independent living Standard 8 The promotion of healthy and active life in older age. 2 out of 3 English Councils only deliver to users with critical and substantial needs - Islington continues to also see users with moderate needs

4 In line with DoH recommendations for adult social care, based on evidence from other councils, the key triggers to establishing a Reablement service were: Demand for home care had increased and was continuing to increase People over 85 was predicted to increase by 12% by 2012 and 45% by 2022 People traditionally employed in the care industry are getting older – making it harder to recruit care workers needed There was commitment from SMT to implement the DoH recommendations, and the following steps occurred: Reablement Project Team and Home Care Board established Business Case prepared and approved (includes service model) Home Care Project Board approves business case Reablement implementation project commenced 4 How Reablement was launched…

5 What is the Re-ablement Service? The Re-ablement Service is an intake service – the Gateway to home care services in Islington Anyone you determine needs home care will go to the Re-ablement Service first The aim of a re-ablement service is to work with users and carers, intensely and for a short period of time, to enable them to live more independently in their own homes The service ill be delivered mainly by Enablers and will last for up to six weeks If service users have ongoing home care needs at the end of that period, they will be referred to the brokerage service, which will place hem with a home care provider

6 What does this mean for service users? If you have an existing home care package – no change arising from the Re-ablement Service Only new referrals to home care services will be directed to the Re- ablement Service Re-ablement is intermediate care and therefore free of charge for the first six weeks Vast majority of users will receive less than six weeks of re- ablement.

7 How will it work? - Overview The Re-ablement Service is an intake service. Anyone you determine needs home care should go to the Re-ablement Service, unless they meet the exclusion criteria: the user has mental health or learning difficulty needs that would prevent them from participating in the Reablement process is not suitable because of particular care needs (e.g. terminal illness) is not old enough (i.e. less than 18 years old) is currently wearing a plaster of Paris cast and is unable to complete any day to day activities. Throughout re-ablement service, user receives regular (at least weekly) reviews.At end of re-ablement period, IF ongoing home care is needed, user referred to brokerage service

8 Re-ablement service – organisation structure Deputy Re-ablement Manager (PO3) Senior Enabler (PO1) Enabler (scale 3 or 4) x 7 Occupational Therapists x 2.0 FTE Administrators (Scale 5) x 3 FTE Re-ablement Manager (PO6) Senior Enabler (PO1) Director of Joint Services Enabler (scale 3 or 4) x 7 Enabler (scale 3 or 4) x 7 Enabler (scale 3 or 4) x 7 Enabler (scale 3 or 4) x 7 Head of Disability & Intermediate Care Director of Adult Social Services

9 Re-ablement service – number of staff PostFTE Re-ablement Manager1 Deputy Re-ablement Manager1 Administrator3 Occupational Therapist2 Senior Enabler5 Enablers35

10 Re-ablement service – roles RoleKey tasksReports to Re-ablement Manager Service management Staff management Financial management Performance management Head of Disability and Intermediate Care Deputy Re- ablement Manager Deputises for Re-ablement Manager Supports the Re-ablement Manager above Line manages Senior Enablers Re-ablement Manager Senior Enabler As Team Leader, lead team of Enablers (8) Receives assessment and care plan from Care Coordinator Risk assessment Re-ablement goal-setting, with input from OTs sets predicted discharge date Assess for and issue basic equipment (all Senior Enablers are Trusted Assessors) Continuous re-assessment reviews Discharge users from re-ablement service Care Coordinator liaison. Re-ablement Manager & Deputy Line managed by Deputy Re-ablement Manager

11 Re-ablement service – roles RoleKey tasksReports to Enabler Work with service user in day to day re- ablement activities Carry out home care tasks where user is unable Update Re-ablement Action Plan Discuss progress with users and carers. Senior Enabler CCA s. Input into multidisciplinary team meetings and final review if ongoing support is needed. Detailed knowledge of FACS Criteria. Supporting and advising Senior Enablers. Liaison with social services teams. Input into the development of Individual Budgets pathway for Reablement Services. 2 Support Advisors that are professionally supervised by social work team

12 Re-ablement service – roles RoleKey tasksReports to Occupational Therapist Develop and deliver induction and training to Enablers and Senior Enablers Conduct regular audits of each teams cases with the Senior Enabler and Enablers in the team Set re-ablement goals and carry out re- ablement reviews with Senior Enablers Support Re-ablement Manager in managing and monitoring the services strategic objectives. Report to Re-ablement Manager when working in the service. Line managed outside re-ablement Service Administrator Maintain Webroster Support Senior Enablers in producing work programmes Assign referrals to Senior Enablers Produce and update team schedules/ work programmes Support the Re-ablement Service in all administrative tasks. Re-ablement Manager and Deputy

13 Re-ablement service – referral to discharge process…

14 Care Manager Re-able.Mgr/ Deputy Senior Enabler Enabler Service User 1.Overview assessment, care plan & predicted re- ablement outcomes 2. Home care? 4.Receive & check referral 9. Review outcomes, agree goals & produce action plan and set predicted discharge date 8. Conduct risk assessment 14. Carry out tasks in plan 13. Hand over folder & plan to user. Allocate Enabler(s) 12. Assess for basic equipment & issue 16. Discuss progress 20. Inform Care manager 21. Re-ablement goal review (min. weekly) 23. Goal review & discharge planning 29.Complete questionnaire & post 24. Final tasks, inform user, hand over questionnaire to user 28.Statutory review & refer to other services 25. Other services? 26.Statutory Review & discharge 7. Allocate Senior Enabler 6. Enter into SWIFT & Webroster 17. Discuss progress 18. Discuss progress 11. Agree goals & action plan and predicted discharge date 5.Determine if rapid response Y 3. Refer to Re- Ab Service 19. Update action plan 20.Check progress (min. weekly) 15. Carry out tasks in plan N Y OT 10. Review outcomes, agree goals & produce action plan and agree predicted discharge date 22. Re-ablement goal review 27.Statutory Review & discharge Act as consultant to Enablers & Senior Enablers Week before last

15 Details of current Reablement Service When did the service become operational?April 2008 What are the current annual volumes?2008/ 2009 Admissions = / 2010 Admissions Quarters (1 – 3) = 434 Intake & assessment / Hospital discharge model? Yes Selection / Deselection model?De - selection - The service has a minimum exclusion criteria Entry subject to FACS?Yes - Islington responds to moderate level of need. Service subject to charge?No the service is free of charge In house / outsourced model?In House / 2010 dataQuarters 1- 3 No further homecare package required at end of reablement phase64% Reduced homecare package required at end of reablement phase11% Assessed homecare package at start maintained at end of reablement phase2.% Assessed homecare package at start increased at end of reablement phase17% User did not complete reablement phase5% Performance

16 Activity % of episodes exiting Reablement service type

17 Activity – People exiting Reablement with home care need comparison with potential hours

18 Slide Activity – AVLOS days

19 Activity - Total difference in weekly home care hours needed following Reablement

20 What worked well: Integration within the Intermediate Care Pathway Client consultation and feedback Enabling model leading to reduction in long term home care packages. Facilitation of hospital discharges reducing acute delayed transfers of care. Accurate monitoring of performance and mechanisms for auditing In House team benefitting from training packages investment into the process Reducing the no of home care What didnt work well: Embedding the enabling philosophy with members of staff who were used to a home care philosophy Home Care and Reablement sharing same office accommodation 20 Learnings

21 Reablement plans to further integration within Intermediate care services to support the work related to: Poly systems Urgent Care Centre Prevention of admission Health Promotion Increase access to services by targeting hard to reach communities Individual budgets and the personalisation agenda 21 Future aspirations

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