WE ARE Jackie Potts – Physiotherapist John Hayward – Social Worker from the Newport Reablement Team

NEWPORT INTERMEDIATE CARE SERVICE L.T.C.N P.A.T.H RAPID RESPONSE NURSINGP.I.L.S REABLEMENT TEAM COMMUNITY PHYSIOTHERAPY PSYCHIATRIC LIAISON NURSE EXPERT PATIENT CONSULTANT STROKE ADVISORY SERVICE Promoting Independent Living Skills

Newport Reablement Team Newport Reablement Team PHYSIOTHERAPY>>> <<<OCCUPATIONAL THERAPY SOCIAL WORK>>> <<< NURSING Reablement Assistants / PILS carers

Types of client Assessed by Reablement: Orthopaedic Musculoskeletal Neurological Respiratory Cardiac Fallers Medical

Social Worker Reablement assessments Care planning Care monitoring / reviewing Carers assessments Benefit work Alternative accommodation planning Falls data base management etc. Supervision of other staff / management support Oh yes and preparing Power point presentations !

Staff Nurse Assessment of medical issues Continence Monitor Obs Address medication Liaise with DN,RR,GP Other…

Occupational Therapy Equipment & to make environment safe Active therapy Transfers Pacing Cognitive assessments Promote sequencing of tasks Facilitation of movement

Physiotherapy Assx mobility, gait, balance, exercise tolerance, physical abilities. Berg Assx tool Dynamic balance Therapy Personal exercises Balance programme Gait – re-education Facilitation of movement Chest management (COPD)

Reablement assistants x 5 80% PT – 20% OT Follow set program with PT/OT assx, goal plan, berg score, exercise sheet, balance or activity plan. Single or double handled clients equipment.

Referral IN Assessment Tools CRT programme Situation Inputs Outputs Outcomes Discharge review FALLS FORM DATA REVIEW

Initial visit / screen inputs / outputs Unified Assessment - Domains Refer on to other services Refer to team members Provide a reablement programme Triggers a FALLS assessment

Assessment see data base Medical problems (falls history) Gait & Balance Footwear & feet Osteoporosis Fear of falling Cognitive Environment Continence Environment BP Medication Nutrition

Bundles Falls driver diagram 1.Trigger bundle – set a trigger. devise a screening tool, log info, GP template 2.Assessment – use assessment form to gain appropriate information 3.Intervention – refer on to services, OT /PT within the team, involve GP or falls service not there yet ! 4.Monitoring – not there yet !

PDSA x 1 Falls trigger / criteria (3 month) Assessment form (designed) 1 page (criteria – UAP) MDT (everyone could use) Cover all areas ( used 1000 lives template)‏ Client details ( date, assessor etc )

PDSA 2 Changes to assessment tool. (3 month trial) Problem : different interpretation of what the questions were asking by different professionals. Problem : unsure where/who to refer on Problem : yes / no, is the issue already being addressed. Result: the form was altered, but still keeping it to a single page.

Falls collaborative Workshop 2 Introduced to RISK tools Database

PDSA X 3 Trigger: workshop 2 Aim for a RISK Assx tool. Pre post differences Sign post to services YES / NO guidance Tool taken on by Community Physio & others See our story board

S.M.A.R.T Specific Measurable Achievable Realistic / Relevant Timed / Tangible What can’t be measured – can’t be managed

Fear

First analysis of the use and scoring on the revised tool Sample size 10 completed forms * Early figures are most encouraging – however we need to drill down into the YES scores that didn’t change. Story Board for learning set 3, 16 th March 2011

What next… Bundle 4 : Monitoring ? Initiate Bespoke Plan On Need Date Plan Agreement With Patient/Famil y/Carers Date Date Of Agreed Timescales and Review Date Copy Of The Plan To Go To The GP Date Review The Compliance With The Plan Date Evaluate the Efficacy of the Plan Date Update or Close the plan & Update Falls Log Date

I think our work here is done.

QUESTION TIME