1. Integrated Rehabilitation Teams
Enabling Risk – Personal Outcomes Network

2. Enabling Risk
Risk
any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury
Ref: WHO
Enabling
supplying with the means, knowledge, or opportunity to do something
Ref: Freedictionary

3. Systems to “support” risk?
Risk assessments
Prioritisation frameworks
Eligibility / Criteria
Pathways

4. Taking the risk with service re-design in North Lanarkshire
Rehab in off site beds
CARS
Community OT’s
Domiciliary Physiotherapy

5. An Integrated Vision – Demonstrator Team
Professional AHP support
Pharmacy
Dedicated Admin
SALT
Community Rehab (CARS)
Community OT’s
Domiciliary Physio
Off site bed Rehab
Located together
Central referral
Joint screening

6. Making Life Easier – self management
The Rehab Sandwich
Off site bed rehab
Reablement
Making Life Easier – self management
Discharge to Assess D2A
Rehabilitation

7. Discharge to Assess (D2A)
Home support
Discharge Coordinators
Acute discharge hubs
Rehab Teams
Team Lead
Equipment & Adaptation Service
Acute sites
Community alarm
2 AHP discharge coordinators – 1 per acute site.
Role – developing referral pathway and screening referrals, working jointly with Team Leads to arrange assessment and services.

8. D2A Achievements March – August 2019
Criteria
Why?
People are medically well, may still require care services and support to be discharged home.
Assessment is undertaken in familiar home environment.
More positive outcomes with family/carers more involved in assessments/planning.
Longer stays in hospital can lead to worse health outcomes
Risk of falls
Infection
Deconditioning
Reduced confidence
Reduce duplication in assessments
Improve hospital flow

9. Early Length of Stay Data
Discharge with D2A
Suitable but not discharged with D2A
Overall length of stay = 6.3 days (average)
Average length of stay after referral to D2A = 1.8 days
Overall Length of stay = 10.9 days (average)
Average length of stay after referral to D2A = 7.1 days

10. The Impact £££
120 discharges – March - August Average 5 days less stay per discharge saved = 600 bed days

11. Impact – John’s Personal Outcomes
Chronic COPD – admitted with chest infection. Antibiotic treatment – stable.
Referred for D2A – arranged discharge for same day.
Assessment identified need for Care at Home, basic equipment, no long term need for community alarm.
Immediate rehab goals identified.
Care at Home was reserved from reablement team – quick feedback to confirm.
Outcome – 7 days – withdrawal of Care at Home and John back to his baseline.
John felt he improved quicker when he got home than when he was on the ward.
Less risk of hospital acquired infections.
Acute admission days saved.

13. Inreach
Community responsibility to facilitate discharge back home. You’re in hospital lets start working on how to get you back home. The aim for discharge is everyone’s responsibility. What really needs to be done within hospital?

14. Better Outcomes
Home based assessments leading to more accurate goals and interventions.
More family involvement
Less over prescription of services and equipment.

15. Any questions?

16. grahama@northlan.gov.uk Alison Graham @AlisonG92303514
Want to find out more?
Alison

17. New work within Shotts Prison Service
Exciting Horizons
New work within Shotts Prison Service
Dietetics linking with rehab teams
Pharmacy in GP practices – medication re-alignment with home support services