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					Future Development of Re-ablement Services –
East Midlands Re-ablement Network
24th Care Services Efficiency Delivery: supporting
     January 2011                                        1
   sustainable transformation
Re-ablement – What Does “Good”
Look Like? – Some Characterisitics

• Between 80% and 90% of people being assessed for eligibility
  should benefit from Re-ablement – so the service should have
  the capacity to meet this demand
• As a result of receiving Re-ablement, at least 50% don’t need
  any ongoing Dom-care support – for at least 1 year
• As a result of receiving Re-ablement, at least 25% need a lower
  level of ongoing Dom-care support
• Re-ablement teams are achieving at least 50% contact time
• Re-ablement is both holistic philosophy and practice (addresses
  physical, financial, social & accommodation needs)
• People are re-abled with (as needed) Telecare, Equipment and
• Social Care Re-ablement services are operationally integrated
  with Community and Acute Healthcare services
East Midlands Re-ablement Services -
Operational Development Priorities

• Improve Outcomes Performance:
   – Increase Capacity – all who would benefit from Re-ablement should
     get it
   – Improve Re-abler Productivity
   – Include Telecare and Equipment in the Re-ablement Offer
• Improve Processes & Systems for Performance
   – Is all activity data collected?
   – Do you have the information you need to manage:
       • Re-ablement episodes for individual service users?
       • The overall service – day-to-day, month-to-month-year-to-year
   – Can you convince your councillors that your Re-ablement service is
   – Can you successfully make the case for more investment?
East Midlands Re-ablement Services –
Strategic Development Opportunities (1)

• Post-Discharge Services & Re-ablement:
   – Additional Funding Stream is £70m (10/11) £150m (11/12) £300m (12/13)
   – Funding allocated to PCTs (Years 1 & 2)
   – PCTs to work with Councils, Foundation / NHS Trusts and Community
     Health Services in developing plans to “use the money to facilitate seamless
     care for patients on discharge from hospital and to prevent avoidable
     hospital re-admissions”
   – For local decision as to how much is spent on NHS services and on Social
     Care services
   – Some of the funding to be used to develop “current Re-ablement capacity in
     Councils, Community Health Services, and the Independent / Voluntary
     sector – according to local needs”
   – PCTs can transfer money to local partners, or to pooled budgets “wherever
     this makes sense locally”
   – From 11/12 Further additional funding will arise from PCTs not paying
     Trusts for certain emergency re-admissions up to 30 days from discharge
   – From 12/13 Trusts will have responsibility for “discharge date plus 30 days”
     care - so will commission and / or provide these services
Potential Scope of Post-Discharge
Support Services (Extracted from NHS PbR
Guidance 2011/12)

•   The types of post-discharge support that might be included in hospitals’
    30 day responsibility include:
     –  Re-ablement – primarily social care services to help people with poor physical or
        mental health accommodate their illness by learning – or re-learning the skills
        necessary for daily living
     – Intermediate Care - time-limited, residential or community based services, in
        community hospitals or other settings, designed to help people make a faster and more
        complete recovery from illness
     – Rehabilitation - medical treatment to help restore physical functioning following a
        hospital admission or procedure. Examples include physiotherapy following
        orthopaedic surgery or speech and language therapy following a stroke
     – Community Health services – provided by district nurses and others
     – Follow-up outpatient attendances.
•   DH will also consider including:
     – Drugs – to give clarity to the supply of drugs to patients on discharge from hospital
     – Equipment.
•   DH anticipate that the following services will be excluded from hospitals’
    responsibility for post-discharge support:
     – Pre-existing residential and home care provided by local authorities
     – GP provided care
East Midlands Re-ablement Services –
Strategic Development Opportunities (2)

• Winter Pressures Funding (10/11) and Specific PCT Allocations
  for Social Care (11/12 and 12/13):
   – Additional Funding Stream is £162m (10/11) £648m (11/12) £622m (12/13)
   – Funding allocated to PCTs (Years 1 & 2) but must be transferred to councils
     to “invest in Social Care services to benefit Health, and to improve overall
     Health gain”
   – PCTs and councils to agree jointly on services for investment, and on the
     outcomes from the investment. Transparency and efficiency will be key
     factors, and councils will keep PCTs informed of progress using
     “appropriate local mechanisms”
   – For 10/11 local shares of the £162m “could be invested in:
        •   Additional short-term residential care places, or respite and intermediate care
        •   More capacity for Home Care, investment in equipment, adaptations and Telecare
        •   Investment in Crisis Response teams, and other preventative services, to avoid unnecessary
            admission to hospitals
        •   Further investment in Re-ablement services”
   – For 11/12 and 12/13 local shares of the £648m and £622m could be used to
     “support and maintain existing services, such as Telecare, community-
     directed prevention (such as falls prevention), community equipment and
     adaptations, and crisis response services”.
Discussion Groups – Points to

• What are the operational development priorities for Re-ablement
  in your councils going forward into 11/12?
• The Post-Discharge Services & Re-ablement policy initiative
  creates both opportunities:
    – More funding
    – Integration of Re-ablement with Community Health and Acute Health
    and threats:
    – Entry of Trusts from 12/13 as commissioners / providers of Re-ablement
    What needs to be done in your council to prepare for this?
• Is there a role for regional co-ordination / networking on Re-

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