Improving Care Coordination with Occupational Therapists in Reablement Service Integration
Enhance care coordination and outcomes for older adults through occupational therapists in the reablement service. This project focuses on functional assessments, goal setting, and training for support workers to optimize care pathways and reduce long-term care needs, leading to significant cost savings and improved quality of life.
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Presentation Transcript
Integrated Care Fund Challenge Integrated Care Fund Challenge Session Session Occupational Therapists to Support the Reablement Service
Project Introduction Three Band 6 Occupational Therapists were appointed to support the Health and Social Care Occupational Therapists completing functional assessments for Reablement, their role is pivotal in the link between acute hospitals, community short term pathway and Reablement pathway. Prior to this investment Reablement assessments were carried out by Care Management staff who were unable to describe the persons functional performance and set relevant goals. 1 Occupational Therapist in Llanelli CRT in-reaching into PPH 2 Occupational Therapists in TTT CRT in-reaching into GGH
Project introduction what needed to happen All OT s completing SSWBA to trigger Reablement OT goals and how they will be achieved transferred to service delivery plan Support workers carry out goals Feedback in pathway Right individuals accessing Reablement Training for all Reablement Support Workers, Seniors, Supervisors and Managers Training programmes commenced 1stOctober 2018
Funding arrangements Funding arrangements: Budget: Funding from ICF: Any other funding: Spend 2017/18 (incl spend to date): Projected 2019/20 budget required:
Project tie-in with ICF objectives The project supports the following ICF objective: Improve care coordination between social services, health, housing, third and independent sector, to focus on preventative care and avoid unnecessary hospital admission or delayed discharge for older people, particularly the frail elderly. An Occupational Therapist carries out a functional assessment and determines what is important for the individual to achieve, this isn t solely about washing, dressing and meal preparation but about their occupations and what is important to the person.
Project key achievements Performance, Activity, Performance Indicators SAVINGS Length of time before needs change POTENTIAL SAVINGS Length of time before needs change 6 months 1,259,595 541,919 - - - 1,801,513 3,603,027 12 months 2,519,189 1,083,837 18 months 6 months 12 months 18 months Key achievements and outcomes Activity Performance indicators Value for money / return on investment No long term needs 3,778,784 No long term needs 2,058,420 4,116,840 6,175,260 147,030 294,060 - - - 441,090 Reduced support (assume 50%) Same Support 1,625,756 Reduced support (50%) Same Support Total Savings 5,404,540 Total Savings 2,205,450 4,410,900 6,616,350 2,000,000 Cost of the Service Ratio of savings to cost 0.90 1.80 2.70 1.10 2.21 3.31 Break even point - weeks N.B. PM20b performance indicator 2016/17 (% of service users who do not have a long term care package 6 months after Reablement) i.e. After 6 months, 40% of service users had a long term package of care. 29 Break even point - weeks 24 59.34%
Value for money Currently whilst the employed Occupational Therapist are referring individuals who have Reablement potential, Care management staff are still referring who perhaps don t have potential and are then clogging up Reablement. Reablement need to ensure they are providing a proactive service as far too may people are going to long term. The Reablement Service isn t currently delivering on financial outcomes, however a substantial amount has been invested in the last year to change the culture.
Key case study / studies Case study 1 Returning to shopping Case study 2- Returning to use stairlift to access kitchen then shops etc. Case study 3 Personal care and in 6 weeks totally independent
Sustainability plan Occupational Therapist carrying out these functional assessments is the recommended way forward for individuals to maximise their functional performance in what is important to them. It was envisaged that Care Management staff would no longer carry out these assessments but currently this is still happening, this is also as a result of some historical access criteria issues.
Project development It is my belief that the investment the Occupational Therapy Service has invested in assessments, time and training that the current Reablement service will start to deliver on a Reablement service achieving higher outcomes for individuals.
Conclusion This has been a massive change for Occupational Therapists due to mainly IT issues. The relationship between OT and Reablement staff has Improved. The Reablement Service needs to be confident that they are providing a Reablement service promoting independence. Service Lead for OT is now meeting monthly to achieve this.
