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Islington - Joint Services Reablement Team

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Islington - Joint Services Reablement Team. Mary Jamal Head of Disability and Intermediate Care . Before Reablement…. Background Contracts with eight external providers An in house home care service specialising in users with dementia

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Islington - Joint Services Reablement Team

Mary Jamal

Head of Disability and Intermediate Care


Before Reablement…


Contracts with eight external providers

An in house home care service specialising in users with dementia

A small rapid response and enabling service delivered by an external agency (in operation since 2004)


All the contracts monitored with the exception of the home care team activity

Based on a small sample size activity from the rapid response agency, there was evidence of 56% of clients had their home care hours reduced and 78% of clients discharged had no on going home care or a reduced package

Budget spend

Home Care budget was around 17% of the budget for Islington Adult Social Services

Home care spend increased by 7% from the financial years 2005/6 (from 11.9 million to 12.7 million)

Was predicted to increase by 4% 2006/7 (from 12.7 million to 13.2 million)

why set up a reablement service
Why set up a Reablement service?

Fit with government policy

The four key objectives of the White Paper ‘Our Health, Our Care, Our Say’:

better prevention with earlier intervention

more choice

tackle inequality & improved access to community services

people with long-term conditions supported to manage their conditions

The National Service Framework for Older People:

Standard 3 Intermediate Care: “prevent unnecessary acute hospital admissions, support timely discharge and maximise independent living”

Standard 8 The promotion of healthy and active life in older age.

2 out of 3 English Councils only deliver to users with ‘critical’ and ‘substantial’ needs - Islington continues to also see users with ‘moderate’ needs


How Reablement was launched…


In line with DoH recommendations for adult social care, based on evidence from

other councils, the key triggers to establishing a Reablement service were:

Demand for home care had increased and was continuing to increase

People over 85 was predicted to increase by 12% by 2012 and 45% by 2022

People traditionally employed in the care industry are getting older – making it harder to recruit care workers needed

There was commitment from SMT to implement the DoH recommendations, and

the following steps occurred:

Reablement Project Team and Home Care Board established

Business Case prepared and approved (includes service model)

Home Care Project Board approves business case

Reablement implementation project commenced

what is the re ablement service
What is the Re-ablement Service?
  • The Re-ablement Service is an ‘intake’ service – the ‘Gateway’ to home care services in Islington
  • Anyone you determine needs home care will go to the Re-ablement Service first
  • The aim of a re-ablement service is to work with users and carers, intensely and for a short period of time, to enable them to live more independently in their own homes
  • The service ill be delivered mainly by Enablers and will last for up to six weeks
  • If service users have ongoing home care needs at the end of that period, they will be referred to the brokerage service, which will place hem with a home care provider
what does this mean for service users
What does this mean for service users?

If you have an existing home care package – no change arising from the Re-ablement Service

Only new referrals to home care services will be directed to the Re-ablement Service

Re-ablement is intermediate care and therefore free of charge for the first six weeks

Vast majority of users will receive less than six weeks of re-ablement.

how will it work overview
How will it work? - Overview

The Re-ablement Service is an ‘intake’ service.

Anyone you determine needs home care should go to the Re-ablement Service, unless they meet the exclusion criteria:

  • the user has mental health or learning difficulty needs that would prevent them from participating in the Reablement process
  • is not suitable because of particular care needs (e.g. terminal illness)
  • is not old enough (i.e. less than 18 years old)
  • is currently wearing a plaster of Paris cast and is unable to complete any day to day activities .

Throughout re-ablement service, user receives regular (at least weekly) reviews.At end of re-ablement period, IF ongoing home care is needed, user referred to brokerage service


Re-ablement service – organisation structure

Director of Adult Social Services

Director of Joint Services

Head of Disability & Intermediate Care

Re-ablement Manager (PO6)

Administrators (Scale 5) x 3 FTE

Occupational Therapists x 2.0 FTE


Re-ablement Manager (PO3)

Senior Enabler (PO1)

Senior Enabler (PO1)

Senior Enabler (PO1)

Senior Enabler (PO1)

Senior Enabler (PO1)


(scale 3 or 4) x 7


(scale 3 or 4) x 7


(scale 3 or 4) x 7


(scale 3 or 4) x 7


(scale 3 or 4) x 7


Re-able.Mgr/ Deputy

Service User

Senior Enabler

Care Manager



8. Conduct risk assessment

4.Receive & check referral

1.Overview assessment, care plan & predicted re-ablement outcomes

11. Agree goals & action plan and predicted discharge date

10. Review outcomes, agree goals & produce action plan and agree predicted discharge date

9. Review outcomes, agree goals & produce action plan and set predicted discharge date

5.Determine if rapid response

2. Home care?

6. Enter into SWIFT & Webroster

12. Assess for basic equipment & issue

Act as consultant to Enablers & Senior Enablers


3. Refer to Re-Ab Service

13. Hand over folder & plan to user. Allocate Enabler(s)

7. Allocate Senior Enabler

15. Carry out tasks in plan

14. Carry out tasks in plan

17. Discuss progress

16. Discuss progress

18. Discuss progress

20.Check progress (min. weekly)

20. Inform Care manager

19. Update action plan

21. Re-ablement goal review (min. weekly)

22. Re-ablement goal review

Week before last

24. Final tasks, inform user, hand over questionnaire to user

29.Complete questionnaire & post

23. Goal review & discharge planning

28.Statutory review & refer to other services

25. Other services?



27.Statutory Review & discharge

26.Statutory Review & discharge

What worked well:

What didn’t work well:


Embedding the enabling philosophy with members of staff who were used to a ‘home care’ philosophy

Home Care and Reablement sharing same office accommodation


Integration within the Intermediate Care Pathway

Client consultation and feedback

Enabling model leading to reduction in long term home care packages.

Facilitation of hospital discharges reducing acute delayed transfers of care.

Accurate monitoring of performance and mechanisms for auditing

In House team benefitting from training packages investment into the process

Reducing the no of home care


Future aspirations


Reablement plans to further integration within Intermediate care services

to support the work related to:

Poly systems

Urgent Care Centre

Prevention of admission

Health Promotion

Increase access to services by targeting hard to reach communities

Individual budgets and the personalisation agenda