A Delivery Framework for Adult Rehabilitation in Scotland

1. A Delivery Framework for Adult Rehabilitation in Scotland Scottish Executive, February 2007

2. Delivery Framework for Adult Rehabilitation in Scotland Purpose and vision “ to give strategic direction and support to all health and social care services and practitioners who deliver rehabilitation services to individuals and communities” The Purpose and vision of the Delivery Framework for Adult Rehabilitation in Scotland is :- “ to give strategic direction and support to all health and social care services and practitioners who deliver rehabilitation services to individuals and communities” It outlines new models for the delivery of rehabilitation services, and makes several recommendations for implementation. The Purpose and vision of the Delivery Framework for Adult Rehabilitation in Scotland is :- “ to give strategic direction and support to all health and social care services and practitioners who deliver rehabilitation services to individuals and communities” It outlines new models for the delivery of rehabilitation services, and makes several recommendations for implementation.

3. Focus on core principles of rehabilitation relating to:- Older people Adults with long term conditions Vocational rehabilitation The framework addresses specific issues relating to rehabilitation three target groups:- Older people, People with long term conditions, and People returning to work after a period of absence or those who wish to stay in employment, …all of which apply across the spectrum of rehabilitation services, and underpin many of those delivering stroke care. It is also explicitly linked to existing work streams of anticipatory care, unscheduled care, planned care, self managed care and the management of all long term conditions. The role of the rehabilitation coordinator is supported in the framework and is being resourced by the executive in each health board – to map services, redesign services where required, integrate health and social care services and promote case management within teams. The most important thing for people and their carers is that they want professionals to discuss their interventions fully and treat them as equal partners in managing their condition The framework addresses specific issues relating to rehabilitation three target groups:- Older people, People with long term conditions, and People returning to work after a period of absence or those who wish to stay in employment, …all of which apply across the spectrum of rehabilitation services, and underpin many of those delivering stroke care. It is also explicitly linked to existing work streams of anticipatory care, unscheduled care, planned care, self managed care and the management of all long term conditions. The role of the rehabilitation coordinator is supported in the framework and is being resourced by the executive in each health board – to map services, redesign services where required, integrate health and social care services and promote case management within teams. The most important thing for people and their carers is that they want professionals to discuss their interventions fully and treat them as equal partners in managing their condition

4. Rehabilitation …. Added value offered by rehabilitation Health gains through return to productive activity and employment Multi-disciplinary & multi agency context Vision for individuals , carers and services to deliver this agenda The framework:- Concentrates explicitly on the added value offered by rehabilitation through earlier anticipatory intervention and the prevention of unnecessary admissions the hospital or other care environments. It explores how rehabilitation can produce health gains through return to productive activity and employment It guides us in developing rehabilitation in a multi-disciplinary & multi agency context & offers a clear vision for individuals , carers and services to deliver this agenda This suggests that we develop and deliver services which are designed around local need and are flexible in meeting the requirements of service users through a modern and effective approach in delivering services. The framework:- Concentrates explicitly on the added value offered by rehabilitation through earlier anticipatory intervention and the prevention of unnecessary admissions the hospital or other care environments. It explores how rehabilitation can produce health gains through return to productive activity and employment It guides us in developing rehabilitation in a multi-disciplinary & multi agency context & offers a clear vision for individuals , carers and services to deliver this agenda This suggests that we develop and deliver services which are designed around local need and are flexible in meeting the requirements of service users through a modern and effective approach in delivering services.

5. Rehabilitation …rehabilitation is fundamentally about enabling an supporting individuals to recover or adjust during this time (when facing challenges to their physical or mental well being, & experiencing an impact on their quality of life), achieving full potential and – where possible – to live full and active lives. Chief Health Professions Officer – Introduction to the Delivery framework for Adult rehabilitation in scotland

6. This model is in the framework and maps out a future model of rehabilitation – which includes different level of management in the rehabilitation process – self management, condition management, and case management. The column on the left describes self management issues – such as use of community leisure facilities, increasing health through technology, and community based voluntary agencies. The central block describes locality based rehabilitation and maintenance teams, including lifestyle management and consideration of case management whilst the right hand side describes specialist rehabilitation teams, such as fast track discharge teams – utilising case management. It includes the integration of service and single points of access. I see the way to implementing this for stroke services in the development and use of existing systems namely the Stroke Managed Clinical Networks which have been established for each health board area – and which work across health, social care and the voluntary sector – with patient and public involvement. Apart from centrally funded rehabilitation coordinators, and national programmes of activity, implementation of the framework will be within existing resources. We have been fortunate in stroke to have extra investment in the last few years – but this is a time for review and redesign if that is appropriate. This model is in the framework and maps out a future model of rehabilitation – which includes different level of management in the rehabilitation process – self management, condition management, and case management. The column on the left describes self management issues – such as use of community leisure facilities, increasing health through technology, and community based voluntary agencies. The central block describes locality based rehabilitation and maintenance teams, including lifestyle management and consideration of case management whilst the right hand side describes specialist rehabilitation teams, such as fast track discharge teams – utilising case management. It includes the integration of service and single points of access. I see the way to implementing this for stroke services in the development and use of existing systems namely the Stroke Managed Clinical Networks which have been established for each health board area – and which work across health, social care and the voluntary sector – with patient and public involvement. Apart from centrally funded rehabilitation coordinators, and national programmes of activity, implementation of the framework will be within existing resources. We have been fortunate in stroke to have extra investment in the last few years – but this is a time for review and redesign if that is appropriate.

7. Recommendations for action Rehabilitation services should be more accessible to those who use services, including direct access when essential 2. Rehabilitation services need to be delivered locally, with a strong community focus There are six statements in the framework which outline the recommendations for action. Many are relevant for all three target groups and the new rehabilitation coordinators will have a specific remit to deliver the recommendations; working in partnership with NHS Boards, local authorities and other agencies. It will be essential for stroke services to review what we already have in place and what needs to be developed alongside these rehabilitation framework recommendations. Rehabilitation services were highlighted as being very important to service users –not so much having difficulty accessing hospital services but more so once people were discharged and requiring community services. This means having better access to rehabilitation without always having to go via the GP, including drop in services, having one point of contact, being flexible to meet the needs of the service user, rather than being time limited by the needs of services, better transport to access rehabilitation services, better information, support and communication, including NHS 24 type of helpline for rehabilitation services and better management of the transition between services – breaking down and traditional boundaries which create blocks to new and effective ways of delivering care. Services need to be delivered locally – but not necessarily at home, we need to make use of existing mainstream facilities for rehabilitation purposes – through engagement with local authorities. A good example of making mainstream services available to people with disability is the development of a national distance learning NVQ level course being hosted by Queen Margaret University in association with several provider agencies including Edinburgh local authority and NHS Scotland. This course is aimed at fitness instructors from the leisure industry, to gain the skills required to provide fitness programmes for people with movement difficulties after a stroke. It aims to facilitate self management and use of existing mainstream community facilities and is a good example of how this recommendation can be put into place for people who have had a stroke. We could establish therapy led rehabilitation centres, expand multi-disciplinary and multi-agency teams providing rehabilitation for people at home, and create better links between specialist rehabilitation and community services. Early supported stroke discharge teams are supported by a robust evidence base and hospital services need to review how they provide rehabilitation to see if earlier, SUPPORTED discharge would be a better way of using funding and if it would meet SOME of the service users needs in a more effective manner. There are six statements in the framework which outline the recommendations for action. Many are relevant for all three target groups and the new rehabilitation coordinators will have a specific remit to deliver the recommendations; working in partnership with NHS Boards, local authorities and other agencies. It will be essential for stroke services to review what we already have in place and what needs to be developed alongside these rehabilitation framework recommendations. Rehabilitation services were highlighted as being very important to service users –not so much having difficulty accessing hospital services but more so once people were discharged and requiring community services. This means having better access to rehabilitation without always having to go via the GP, including drop in services, having one point of contact, being flexible to meet the needs of the service user, rather than being time limited by the needs of services, better transport to access rehabilitation services, better information, support and communication, including NHS 24 type of helpline for rehabilitation services and better management of the transition between services – breaking down and traditional boundaries which create blocks to new and effective ways of delivering care. Services need to be delivered locally – but not necessarily at home, we need to make use of existing mainstream facilities for rehabilitation purposes – through engagement with local authorities. A good example of making mainstream services available to people with disability is the development of a national distance learning NVQ level course being hosted by Queen Margaret University in association with several provider agencies including Edinburgh local authority and NHS Scotland. This course is aimed at fitness instructors from the leisure industry, to gain the skills required to provide fitness programmes for people with movement difficulties after a stroke. It aims to facilitate self management and use of existing mainstream community facilities and is a good example of how this recommendation can be put into place for people who have had a stroke. We could establish therapy led rehabilitation centres, expand multi-disciplinary and multi-agency teams providing rehabilitation for people at home, and create better links between specialist rehabilitation and community services. Early supported stroke discharge teams are supported by a robust evidence base and hospital services need to review how they provide rehabilitation to see if earlier, SUPPORTED discharge would be a better way of using funding and if it would meet SOME of the service users needs in a more effective manner.

8. Recommendations for action 3. A systematic approach to delivering rehabilitation to individuals is required, promoting independence, self management and productive activity Rehabilitation services should be comprehensive and evidence based, should reflect individuals needs at distinct phases of care, and should identify models to ensure seamless transitions 3. Enablement and self managed care requires a systematic approach – service users want channels of communication which allow them, and their carers to take greater control of the management of their care They want us to make more use of volunteer and support groups in designing, delivering and evaluating services; many Stroke Managed Clinical Networks have public involvement sub groups – who contribute to this – but it is just the tip of the iceberg. They want to contribute fully to decision making and not just to approve decisions which have already been made. The & they want flexible systems to support return to work. 4. Service users want their ongoing rehabilitation needs met following discharge from hospital. The transition between hospital and home can be very stressful for patients and carers. Some people are fortunate enough to have stroke nurse follow up – but this not allways the case and equitable access should be a priority along with consideration of other rehabilitation service needs. Key worker or rehabilitation coordinator roles should be explored, and evidence based consistent services, with good communication amongst professionals is what we should be providing for all. 3. Enablement and self managed care requires a systematic approach – service users want channels of communication which allow them, and their carers to take greater control of the management of their care They want us to make more use of volunteer and support groups in designing, delivering and evaluating services; many Stroke Managed Clinical Networks have public involvement sub groups – who contribute to this – but it is just the tip of the iceberg. They want to contribute fully to decision making and not just to approve decisions which have already been made. The & they want flexible systems to support return to work. 4. Service users want their ongoing rehabilitation needs met following discharge from hospital. The transition between hospital and home can be very stressful for patients and carers. Some people are fortunate enough to have stroke nurse follow up – but this not allways the case and equitable access should be a priority along with consideration of other rehabilitation service needs. Key worker or rehabilitation coordinator roles should be explored, and evidence based consistent services, with good communication amongst professionals is what we should be providing for all.

9. Recommendations for action Practitioners and providers in health an social care services need to be better informed about current and evolving roles and expertise within rehabilitation teams. Health and social care professionals need to critically review staff resource deployment through service re-design and skill mix review. 5. Sustainable multi professional teams are key to implementing these services and joint training and improved skill mix is requested. 6. This is around capacity and we are constantly being asked to consider new and innovative ways of using our skills. The role of the key worker or rehabilitation coordinator is highlighted, and we are asked to consider more local community based workers with a review of resource utilisation to see if there are more imaginative and effective ways of using them. Shared expertise and use of mainstream resources – tailored to the needs of people with stroke may just be one way of easing that process. A culture of openness in our approach to reviewing services, I believe is becoming more apparent. As multidisciplinary teams gain strength and the influence of rehabilitation professionals is recognised as key to delivering these services. 5. Sustainable multi professional teams are key to implementing these services and joint training and improved skill mix is requested. 6. This is around capacity and we are constantly being asked to consider new and innovative ways of using our skills. The role of the key worker or rehabilitation coordinator is highlighted, and we are asked to consider more local community based workers with a review of resource utilisation to see if there are more imaginative and effective ways of using them. Shared expertise and use of mainstream resources – tailored to the needs of people with stroke may just be one way of easing that process. A culture of openness in our approach to reviewing services, I believe is becoming more apparent. As multidisciplinary teams gain strength and the influence of rehabilitation professionals is recognised as key to delivering these services.

10. National Implementation National rehabilitation implementation group Funding for Rehabilitation coordinators Rehabilitation Implementation Programme group Rehabilitation Research Consensus Event Managed knowledge Network In order to implement the recommendations the government has proposed five key national actions.In order to implement the recommendations the government has proposed five key national actions.