What was the issue you were addressing or working on?
The aim of the HWCRS is to:
- transfer appropriate people to the HWCRS (e.g. those who meet the agreed criteria)
- work with and encourage service users to regain their level of function with regards to mobility, personal care and kitchen tasks resulting in an increase in confidence and independent living for the service user
- educate the informal care/family regarding the re-ablement approach to care
- encourage socialisation and taking part in mainstream HWC activities
What you did?
The HWCRS is a Change Fund project using a partnership approach to re-ablement and involves HWC (Falkirk Council Social Work Services, Care & Support at Home Services) and ReACH Falkirk (Health Services). The therapists OT & PT work with the service user to plan their goals and outcomes (quality of life/change/process). The re-ablement carers based in Tygetshaugh Court work with the service users over a 2-6 week timeline to achieve these goals/defined outcomes.
The first service user was transferred to the HWCRS on 22/01/2013. There have been 13 service users transferred to date (September 2013). Those discharged home have achieved increased Elderly Mobility scores (EMS) and lower SSA-IoRN scores.
The project is being evaluated using a conversational approach to interviews (Talking Points) and an outcomes-based evaluation methodology. Findings are written up with a brief discussion regarding the service users’ reason for transfer to the HWCRS, verbatim quotations from service user/informal carer interviews, with outcomes charts used to offer an at-a-glance view of outcomes achieved.
What were the outcomes - benefits or otherwise?
Service users have a more intensive re-ablement approach taken regarding their therapy and care over a 2-6 week timeline. All service users discharged from the HWCRS have had positive outcomes, being successfully re-abled to return home to function more independently than on transfer from hospital. If required there can be follow up from the Rehab at Home Service and/or ReACH Falkirk in the service user’s home. As part of the project evaluation service users are contacted by the HWCRS approximately four weeks following discharge. Summary of benefits:
- Hospital bed/staff costs savings
- Avoid transfer to long-term care and the ongoing costs
- Avoid delayed discharge from acute hospital services
- A more intensive therapy plan to encourage recovery/independence
- Peace of mind for informal carer/family on transfer to the HWCRS and following discharge
Contacts - to find out more
Gail MacNamara, firstname.lastname@example.org 01324 670223