What was the issue you were addressing or working on?
Prior to the establishment of the Duty and Response Team, there was no community rehabilitation team and social care and health elements of support operated independently, albeit collaboratively with one another. This still meant duplication of information sharing and assessment processes for older people requiring the service. The Change Fund enabled the addition of Physiotherapy and Occupational therapy professionals to join the Adult Wellbeing duty and response team to form a multidisciplinary duty, response and rehabilitation team.
What you did?
The Response and Rehab service aims to work collaboratively within an existing Social Care team to provide multidisciplinary rapid and intense rehab input to avoid admission to hospital, support early discharge and support East Lothian’s elderly population in their own home. The service also supports a falls screening and prevention programme. It aims to give every client a positive experience of an integrated team, providing joined up rehab, enables the right professional to take charge of case and avoids client having to ‘repeat’ story to multiple professionals. Excellent communication between health professionals aids client feeling more confident in service.
248 individuals over 65 were supported by the service during 2012/13, with over 1500 individual interventions. Effective partnership working within the new multidisciplinary team and other teams in health and social care in delivering response and rehab service. This has created increased number of referrals (total no. of referrals for period Oct 2012-Mar 2013 was 187, compared with 84 referrals between April – Aug 2012) indicating the service is providing increased care/ rehab in the community. The number of joint visits/ interventions has increased, providing improved holistic care/ rehab to service users. (Oct 2012 13% of initial visits were joint, March 2013 35% of initial visits were joint).
What were the outcomes - benefits or otherwise?
Overall data for the partnership in relation to delayed discharges and unscheduled admissions to acute hospital services shows that these are still increasing. This service has however demonstrated and active contribution towards addressing these issues and offering a quality service that is holistic in its approach. Feedback from individuals and referrers has been very positive, referring to clear referral pathways, reduced duplication of assessment and information sharing, and the speed of the response to crisis situations. Referral numbers are increasing due to raised awareness of team. The team is well established with EL Council with good and effective relationship between Health and Social Care.