The East Lothian Health & Social Care Partnership aims to deliver community services that are aligned with the 20:20 Vision and Shifting the Balance of Care. These recommend people are supported to return home with minimal risk of readmission, through the development of multi-agency approaches. With this ethos in mind the START project was initiated. Project Aims:
1. Create an Integrated Community rehabilitation team providing high intensity, high frequency OT /PT interventions.
2. Embed a patient-focused approach with streamlined processes/pathways.
3. Reduce length of hospital stay and prevent avoidable admissions through a viable community based model.
4. Foster a culture of early intervention and self management.
· The START project (Short Term Assessment and Rehab Team) was undertaken, July 2018 - June 2019. It built on our successful Discharge to Assess pathway and focused on 3 GP Practices in East Lothian.
· START facilitated early supported discharge by providing goal orientated, high frequency/ intensity rehabilitation, in a community setting.
· It was an integrated service including - Occupational Therapists, Physiotherapists and Community Care Workers across the Health & Social Care Partnership.
· Alongside START, patients were supported by STRIVE, a third sector organisation for ongoing community reintegration.
· Weekly in-reach meetings with GPs/DNs improved communication and enhanced effective working relationships.
· This led to the development of a prevention of admission pathway with referrals received directly from GP’s.
· Twice weekly clinical team huddles were established to ensure patient focused care and goal orientated interventions.
· Weekly reporting underpinned re-evaluation and evolution of the service.
· 120 patients were seen by START –
o 96 facilitated hospital discharge
o 24 prevention of admissions
· Patient outcomes – 111 patients remained at home, 73 self-managed and required no onward referrals.
· 93% of patients and carers reported START was beneficial and 100% of GP’s found it useful and improved practice.
· This service is a sustainable and effective long term model, with the opportunity for further development and evolution to meet the needs of the patients.
· Patient-centered, goal orientated, home based rehabilitation can be successfully delivered in the community.
· Co-location and regular contact are key to sustaining effective communication and relationships between H&SC teams across Primary and Secondary Care.
Cost and savings
No further information.
The START project has shown the immense benefits that can be delivered to both patients and carers, while also positively impacting patient length of stay and flow, through the implementation of an integrated H&SC team. This team is innovative in it's structure and outcome, with a model of rehabilitation that is unique, due to the removal of pre-existing referral and treatment boundaries and established links with GP practices. As a service we now plan to establish 3 geographical Integrated Rehabilitation clusters across East Lothian to complement and enhance existing primary care and community services.
Top three learning points
No further information.
This project was undertaken within existing resources, no additional funding was required.