1. Community Reablement Winter Beds 2015/16 GP Education and Training Event 17 September 2015 Dr Ben Solway / Shivaun Aveston For any queries regarding the community reablement beds pilot for 2015/16 please contact: Shivaun Aveston, Transformation Lead on 01473 770131 or Julie Taylor, Redesign Project Manager on 01473 770168 1

2. Community Reablement Winter Beds What is the plan for 2015/16? Background Community beds have a significant impact on health outcomes, demand and capacity management for acute hospitals, system wide resilience and patient experience. In April 2015 a review of community beds utilisation (in community hospitals and care homes) was undertaken by IESCCG, to compare against benchmarking activity data from 2014. This informed us about system capacity and the variables of how community hospital beds are used, along with the future community bed needs in Ipswich and East Suffolk. As a result of this, a pilot commenced in June 2015 of eight protected beds at Bluebird Lodge Community Hospital to support ‘step up’ and ‘step across’ care and to test the concept and support admission avoidance. What is the community reablement winter beds pilot for 2015/16? I&ESCCG are keen to continue to support GP practices and the wider system to support admission avoidance by commissioning a number of community reablement beds for winter 2015/16. The focus will be to provide short-term ‘step up’, ‘step across’ and ‘step down’ care in a community setting for the purpose of reablement, (similar to the 2013/14 Baylham/Barham model). These winter beds will be mainly focused for ‘step up’ and ‘step across’ admissions however will also support the wider system by providing the potential for ‘step down’ admissions from the acute Trust during times of escalation. The winter beds will run from Monday 2 November 2015 to 31 March 2016 and will begin with a phased implementation. The CCG are commissioning 10 beds from the Stowmarket area and progressing discussions with additional care providers for another 8 spot purchased beds in Ipswich and 6 ‘virtual’ beds in Felixstowe. A full evaluation will follow to inform the CCG of resilience and future capacity planning for 2016/17. 2

3. Community Reablement Winter Beds Aims and Benefits 3 Aims and benefits of the Community Reablement winter beds include: Securing sufficient community reablement beds in readiness for periods of increased demand and capacity. To support a system-wide response to periods of escalation and surges in demand improving patient flow, maximising use of bed capacity and offering alternative referral pathways of care using step up and step across as part of admission avoidance. Preparedness, responsiveness and building resilience across the system. To support the acute Trust to identify patients suitable for transfer to community beds and provide additional intermediate care bed capacity. To support the acute provider in maintaining the 95% performance A&E target. Benefits to patients Increased patient choice. Focus on return to mobility and independent living. Access to an appropriate care setting for medically stable patients. Opportunity to access community-based care. Reduced admissions to acute hospital.

4. Community Reablement Winter Beds Referral Information What patients will be suitable for the Community Reablement winter beds for 2015/16? Patients will be aged over 18 and registered with an I&ESCCG GP. Patients will be medically suitable (all patients must be discussed/reviewed by the appropriate doctor/GP). Examples might include patients ‘off their legs’, had a recent fall, cannot be left at home safely or requiring a health and social care review or assessment. Patients requiring support unable to ‘normally’ be provided in their own home. Patients able to be cared for safely and with dignity within the care home. Patients not presenting an infection control risk to other patients within the environment. Patients have a predicted discharge date from the community reablement beds within 5-7 days, at which time the patient is predicted to return to a functional level where they could return home (perhaps with additional ongoing support such as basic assistive equipment ongoing rehab input or with a new or existing package of care). Patients placed in the community reablement winter beds will be deemed ‘medically fit’ with a low level reablement need or awaiting care packages. Definitions of care for patients placed in the community reablement winter beds Reablement - general aim to help people accommodate their illness or condition by regaining confidence and learning/re-learning the skills necessary for daily living. Step up care - a pathway for patients who are about to or have tipped into a crisis and who have continuing diagnostic and care needs that cannot be managed in the community setting. Step across care – a pathway for patients who are transferred from A&E following diagnostics and assessment and who require bed- based clinical care for a time-limited period before returning to their own home. Step down care – a pathway for people who have required a non-elective or elective admission and includes transfer of care to a trigger based self-care model. This will include supporting patients who are supported on an early supported discharge pathway. Launch and referral details A referral and admission criteria flowchart is being developed as part of the mobilisation work for the beds and will be sent out as part of a GP briefing pack to all GP practices in the Ipswich and East Suffolk area in preparation for the start date. Referrals can be made from Monday 2 November 2015. 4