Do we truly understanding our community rehabilitation population? : Using data and stratification tools to transform community rehabilitation


The East Sussex Rehabilitation strategy aims to keep people living well in their home for longer. Project deliverables:

· Improve patient experience of rehabilitation and enable community rehabilitation transformation through:

o Understanding system capacity, demand and patient flow into intermediate care services.

o Reduce length of stay in services

o Reduce unwarranted variation in rehabilitation pathways

o Enable optimal decision making

o Improve access to quality rehabilitation

o Improve cost effectiveness of rehabilitation against commissioned tariff

o Support capacity within regional specialist beds by managing moderate complexity within East Sussex

To support the aims of the strategy there was a need to understand and profile the rehabilitation population across East Sussex Healthcare NHS Trust.


The project was underpinned by QSIR methodology where key principles were:

· Development of service and performance indicators to support clarity on the role and function of our intermediate care units. These were socialised across the organisation prior to the start of the project.

· Development of a Rehabilitation Stratification Matrix using standard clinical evaluation tools within rehabilitation: acuity, dependency, complexity scores and measures specific for stroke (NHISS) to support signposting to the right service and reduce variation in pathway.

· Development of an Intermediate Care Database Tool to improve understanding of service use, patient profile , performance and outcome.

· Implementation of the daily rehab board round and completion of the Database Tool, providing data on complexity, dependency and acuity.

· Monthly reports shared with team, division and executive level demonstrating how patient profile may influence expectations around LOS, outcomes and onward pathway choices, further driving rehabilitation service transformation.



· Reduced variation in pathway decision - getting it right first time

· Reduced LOS by 15 days across intermediate care services

· Reduced wait times for Intermediate care bed

· Improved compliance for stroke ESD service surpassing trust stretch target of 25%

· Significant change in referral pathway direct to community bypassing intermediate care

· Effective use of bedded care rehabilitation for more complex cases

· Provide monthly rehab report on performance, changing population profile to support greater understanding of rehab need within the region

· £0.6 million investment in bedded rehabilitation AHP workforce

· Highlight external system pressures that were previously being absorbed within the unit performance.

Conclusion(s): The use of a Stratification Matrix and Intermediate Care Database Tool improve system wide confidence in how we

Cost and savings

reduced LOS across intermediate care by 15 days and reduced excess bed days, data on complexity enabled investment of £0.6million for AHP staff (11.5WTE)


  Supporting confidence in getting patients home first

· Better system understanding of our rehabilitation population and service redesign

· Enhanced appreciation of the value of rehabilitation

· Improved system flow

· Reduced excess bed days within bedded rehabilitation

· Funding for additional 11.5WTE AHP staff

· Improved workforce moral

Top three learning points

No further data 

Funding acknowledgements

No funding sources