Rehabilitation

We define rehabilitation as:

“An active, time-limited collaboration of a person with disabilities and professionals, along with other relevant people, to produce sustained reductions in the impact of disease and disability on daily life. Interventions focus on the individual, on the physical or social environment, or a combination of these.”

Excellent rehabilitation services can significantly improve patient outcomes.

Excellent rehabilitation services can speed up hospital discharge and reduce re-admission rates, thus contributing to the more efficient use of NHS resources.

BUT:

We currently do not have a comprehensive picture of the range, cost and availability of services across the region.

Surgeons, physicians, nurses, therapists, social workers and others often fail to recognise their own roles as agents of rehabilitation, despite their crucial importance in securing good rehabilitation outcomes.

Services are not joined up and can be fragmentary meaning patients do not always receive timely, co-ordinated and sustained interventions to maximise their rehabilitation.

We have set up a regional programme to drive forward improvements in rehabilitation care in the East Midlands.

Creating a standard model of care

We have defined four categories of need which are in line with the Specialised Service National Definitions Set (SSNDS) for Brain Injury and Complex Disability (2010). Patients with more than one category of need require the service meeting their most complex needs. The categories are:

Category A need: patients require co-ordinated interdisciplinary interventions from four or more therapy disciplines with programmes typically lasting 2-4 months or longer. These patients require ‘Level 1 – Specialised’ services at regional or supra-regional level.

Category B need: patients have a range of needs that can be met by what are termed ‘Level 2 – Local (i.e. district-based) Specialist’ services.

These two categories of patient, many with brain injury, have highly complex rehabilitation and medical needs and require services led by consultants in rehabilitation medicine.

Category C need: patients require specialist rehabilitation in relation to specific diagnostic groups (e.g. stroke). They may be medically unstable. Patients typically require rehabilitation interventions involving 1-3 therapy disciplines in programmes lasting up to 6 weeks. Services (termed ‘Level 3a – Other Local Specialist’) are delivered by therapy and nursing teams with specialist expertise in the target condition. Services may be led by consultants in specialties other than rehabilitation medicine (e.g. neurology / stroke medicine).

Category D need: patients have a wide range of conditions but are usually medically stable. They require less intensive rehabilitation intervention involving 1-3 therapy disciplines in relatively short rehabilitation programmes (i.e. up to 8 weeks). The services (termed ‘Level 3b - Local Non-specialist’) may be led by non-medical staff.

All four levels of service are situated within a range of inter-dependencies such as ambulance services, mental health services, and social services.

There is clear leadership and accountability for rehabilitation services
Standard	Indicator
Increase the percentage of provider and commissioning organisations that have an identified lead for rehabilitation services	There is clear identification of managerial personnel to ensure accountability and linkages with other services.
	Appropriate rehabilitation funding structures are clearly identifiable and available to ensure timely, comprehensive rehabilitation appropriate to the patient pathways and patient needs.
	Identifiable representation of all units within the Regional Rehabilitation Network, supplying and sharing outcome and performance data and ensuring coordinated development of rehabilitation service management.
	Clinical leads for services e.g., Acute Trauma Rehabilitation Services in Major Trauma Centres have overall responsibility for the co-ordination and delivery of clinical rehabilitation services.

Rehabilitation services are accessible and equitable
Standard	Indicator
Percentage of patients from ethnic minorities accessing rehabilitation services matches the census data from catchment population	Patients not admitted directly to a disease or symptom specific centre e.g. a major trauma centre are not disadvantaged. Patients have the same access and assessments following critical illness.
Increase the number of patients accessing all phases of rehabilitation	Rehabilitation facilitators are identified for each provider site.

Services are co-ordinated, delivering seamless rehabilitation pathways
Standard	Indicator
An information governance plan, including data definitions, is agreed and in place	Identifiable clinical linkages exist with all relevant providers of rehabilitation care within the region
% of senior clinical staff with access to primary care Summary Care Records	There is identifiable representation of all units within the Regional Rehabilitation Network, supplying and sharing outcome and performance data and ensuring coordinated development of rehabilitation service management.
Increase the percentage of patients who have an appropriately completed Electronic Discharge Summary (EDS) within a maximum of 24 hours, (following discharge - target 100%)	An electronic directory of services is available for all users, health care professionals and social care to ensure rehabilitation and ongoing care facilities are easily accessible
Each GP practice has a clearly agreed protocol with their community health and social care partners covering case finding, personalised care planning, multidisciplinary assessments with specialist medical input and arrangements for monitoring the effectiveness of the protocol	There are clearly defined times and locations for provision of services by MDT and its members. This is supported by documented contractual agreements
Percentage of 111 telephone calls assessed using NHS Pathways that end in a referral to an Emergency Department (ED) expressed as a percentage of total number of calls received	Multidisciplinary team meetings include and liaise with primary care and also social care routinely Standard clinical pathways for critical illness exist across the region, in line with guidelines

Necessary clinical information accompanies the patient from one stage to the next
Standard	Indicator
An information governance plan, including data definitions, is agreed and in place	Clear identification of managerial personnel to ensure accountability and linkages with other services
Increase the percentage of patients who have an appropriately completed Electronic Discharge Summary (EDS) within a maximum of 24 hours, (following discharge - target 100%)	Rehabilitation facilitators identified for each provider site

Patients and families have high quality experiences during rehabilitation
Standard	Indicator
Reduce the number of complaints re: rehabilitation services	All levels of rehabilitation clinical staff receive clinical supervision in order to promote quality of practice, continuous development and personal emotional support. Private spaces are available for rehabilitation practice e.g. for assessments and counselling. Similar spaces are provided for urgent assistance in the event of acute deterioration. Adequate transportation facilities are available to meet the demands and needs of patients and carers.

Patients and families are fully involved in rehabilitation and have as much control as possible of their future
Standard	Indicator
Percentage of patients attending the ED from residential and nursing home care who have a ‘Right Care’ or equivalent clinical care plan in place	Every patient is in possession of an agreed rehabilitation plan and prescription at all stages of the pathway
An expected date of discharge for all patients is indicated within 12 hours of presentation	Short-term and medium-term rehabilitation goals are reviewed, agreed and updated throughout the patient’s rehabilitation care pathway in collaboration with the patient and their family
% of patients who do not have an Expected Discharge Date (EDD)	Facilities used for rehabilitation care contain audio and visual aids to enable patients and carers to access self-help media
Percentage of people with a long-term condition who have an integrated personalised care plan, along with a specified rehabilitation plan	Advanced Care Planning is routinely considered in all patients

Rehabilitation begins as early as possible following diagnosis
Standard	Indicator
An expected date of discharge for all patients is indicated within 12 hours of presentation	Rehabilitation personnel (consultant and multidisciplinary team (MDT) personnel) are available seven days a week.
All patients requiring a specialist review (of rehabilitation needs) will receive it within 12 hours of their initial assessment	Rehabilitation commences in the critical care setting or as soon as possible thereafter. Rehabilitation matches severity and complexity of needs, continuing for as long as necessary to achieve functional potential
An electronic skills based Directory of Services(eDoS) is in place which meets the agreed scope of rehabilitation services and is staffed appropriately	Rehabilitation Facilitators identified for each provider site
Reduce the delay in provision of appropriate equipment for rehabilitation needs	Advanced Care Planning routinely considered in all patients

Rehabilitation assessments and interventions are comprehensive
Standard	Indicator
Proportion of people receiving a comprehensive rehabilitation assessment in Phase 1 and in Phase 2 (100%)	Staff training is linked to regional education and training programmes, with a key lead for each level of service supporting the development of the MDT Patients not admitted directly to a disease or symptom specific centre e.g. a major trauma centre are not disadvantaged. Patients having the same access and assessments following critical illness.
Increase the percentage of physically injured patients being assessed for non-physical conditions	Staff at all levels have appropriate pre- and post-qualification training
All patients requiring a specialist review (of rehabilitation needs) will receive it within 12 hours of their initial assessment	Vocational rehabilitation is available to all patients of working age and is addressed as a key component of their rehabilitation care
Reduce the prevalence of patients unable to return to work, due to lack of vocational needs assessments	Rehabilitation personnel are trained in non-physical as well as physical aspects of rehabilitation. Services have dedicated multidisciplinary teams. Where resources are limited e.g., psychology – units work with partner organisations to arrange adequate capacity to meet the ongoing needs of the patients. Facilities meet standards of the operating framework and will be risk assessed annually in compliance with other guidelines. Appropriate equipment , facilities and staff are available to meet the needs of Type A patients. The service is led by a consultant trained and accredited in Rehabilitation Medicine. The service meets the BSRM standards for specialised rehabilitation services. Full clinical data is supplied annually as defined by the UK National Dataset for Specialist Rehabilitation Services. Staff-patient ratios and team composition follow guidance for Level 1 and Level 2a services .

High quality community services minimise hospital admissions
Standard	Indicator
Reduce the number of bed days for acute and rehabilitation beds by 25%	Rehabilitation facilitators identified for each provider site
Percentage of 111 telephone calls assessed using NHS Pathways that end in a referral to an Emergency Department (ED) expressed as a percentage of total numbers of calls received	Appropriate rehabilitation funding structures clearly identifiable and available to ensure timely, comprehensive rehabilitation appropriate to the patient pathways and needs.
Percentage of patients admitted due to breakdown of informal care or family, primary and community health or social care – as a percentage of total admissions	Appropriate rehabilitation funding structures clearly identifiable and available to ensure timely, comprehensive rehabilitation appropriate to the patient pathways and needs. Identifiable clinical linkages with all relevant providers of rehabilitation care within the region.
Percentage of patients maintained in the community setting for more than three months, following intermediate care and rehabilitation	Identifiable representation of all units within the Regional Rehabilitation Network, supplying and sharing outcome and performance data and ensuring coordinated development of rehabilitation service management..
Ratio of re-admissions (within 30 days) compared to total discharges	Rehabilitation commences in the critical care setting or as soon as possible thereafter. Rehabilitation matches severity and complexity of needs, continuing for as long as necessary to achieve functional potential.
Average length of stay for acute episodes requiring subsequent rehabilitation	Rehabilitation commences in the critical care setting or as soon as possible thereafter. Rehabilitation matches severity and complexity of needs, continuing for as long as necessary to achieve functional potential.

Rehabilitation processes are prompt and timely
Standard	Indicator
Reduce the delay in provision of appropriate equipment for rehabilitation needs	An electronic directory of services is available for all users, health care professionals and social care to ensure rehabilitation and ongoing care facilities are easily accessible.
Occupied bed days of patients declared medically well or waiting for transfer	Teams are sufficiently flexible to be able to sustain core elements of services when the percentage of staff unavailable at any one time is one standard deviation above the national average for NHS staff absences. Identifiable clinical linkages with all relevant providers of rehabilitation care within the region. Standard clinical pathways for critical illness exist across the region, in line with guidelines.
Percentage of time between the hours of 08:00 until 00:00, within a year, where a rehabilitation co-ordinator is present within the acute Trust	Rehabilitation processes are not delayed due to non-availability of equipment to meet care and rehabilitation needs of individual patients.
Waiting time to access community health therapies essential for discharge e.g. physiotherapy, occupational therapy (target zero %)	Rehabilitation personnel trained in non-physical as well as physical aspects of rehabilitation

Outcomes are led by patient choice
Standard	Indicator
Reduce the percentage of patients newly discharged directly to long term residential or nursing homes(target zero, excluding continuing health care patients)	Identifiable clinical linkages with all relevant providers of rehabilitation care within the region
Ratio of monies spent on adult social care for older people on residential and nursing home care versus community services	Appropriate rehabilitation funding structures clearly identifiable and available to ensure timely, comprehensive rehabilitation appropriate to the patient pathways and patient needs

Developing a rehab plan and prescription

The NICE Guidelines for rehabilitation following critical illness advise the construction of a ‘rehabilitation prescription’. Patients and staff should collaborate in the creation of a written rehabilitation plan and should be clear about the prescription of appropriate interventions. These should be relevant to the patient’s overall aim and to specific short- and medium-term goals, as reflected in measurable outcomes. The plan and prescription can be applied to acute, chronic or progressive conditions.

The plan should be:

person-centred, driven by an individual’s overall aims
jointly created and ‘owned’ by the patient, the family and all involved professionals
current – being adapted as needs change
concrete – easily translated into practical actions, and amenable to audit.

Developing a rehab facilitator role

Co-ordination of rehabilitation is undermined by the transfer of patients from one setting to another – e.g. from ITU to an acute medical ward, or from an acute setting to intermediate care. One proposal to promote a more seamless approach is to develop the role of rehabilitation facilitator. The rehabilitation facilitator would act as a resource within multidisciplinary teams in all settings. The competencies of the rehabilitation facilitator must be adequate to act as a conduit from one point to another on the pathway and as the overseer of successive stages of the rehabilitation process.

In the hospital setting the role of rehabilitation facilitator goes beyond that of discharge facilitator because the rehabilitation facilitator would not only co-ordinate the transfer of patients from one healthcare setting to another, but would also facilitate assessment and rehabilitation following transfer. The rehabilitation facilitator might undertake case management, or might delegate this responsibility to another appropriate resource but would still retain the patient on his or her caseload at all stages of an episode of care. Involvement would be intensive for a few but for most patients the role would be that of overall facilitator of the rehabilitation process, ensuring that the rehabilitation plan is implemented in line with the person’s stated aims, as the patient passes from one facility or stage to the next.

An alternative option for facilitation would be for the role of facilitator to be developed from within an existing MDT, with team-members out-reaching to other units or to the community to continue the facilitation until the end of the rehabilitation process.

In the setting of an acute hospital, a third option would be to assign the facilitative role to community-based professionals who would have an ‘in-reach’ function. The traditional approach is for patients to be ‘pushed out’ into the community. This option, by contrast, allows patients to be ‘pulled in’ to the community by a community-based professional such as a community matron. This option would be especially attractive where the patient is already known to community personnel. In that situation, the primary healthcare team and others would often be in a better position than acute hospital staff to gauge the level of care needed and the level of risk that would be acceptable to the patient.

Other useful links:

NHS Specialised Services National Definitions Set

NICE Guidance for Critical Illness Rehabilitation