Co-ordinated, integrated and fit for purpose: A Delivery Framework for Adult Rehabilitation in Scotland

3. A new approach to rehabilitation

Rehabilitation

Rehabilitation interventions are designed to make positive impacts on individuals and carers, enabling them to live their lives to their fullest potential. Rehabilitation is a concept that has broad applicability across health and social care professions and agencies. It can be defined in different ways within different contexts and means different things for different client groups.

There is no universally accepted definition or theoretical model to describe rehabilitation. The King's Fund, however, has produced a working definition which describes rehabilitation as:

A process aiming to restore personal autonomy to those aspects of daily life considered most relevant by patients or service users, and their family carers.¹⁶

This definition reflects the fact that the needs of individuals and carers are at the heart of rehabilitation. Developing enablement approaches will allow services to work in partnership with individuals and carers to provide professional support or interventions when required and to ensure best use of resources and best outcomes for individuals and carers.

A more detailed analysis of rehabilitation, which relates more to specialist roles and focuses on structure, process and outcomes, is provided by Wade et al.¹⁷ (Box 3.1).

Box 3.1 Rehabilitation 17

Structure A rehabilitation service consists of a multi-disciplinary team of people who: work together towards common goals for each patient; involve and educate the patient and family; have relevant knowledge and skills; can resolve most of the common problems faced by their patients. Process Rehabilitation is a reiterative, active, educational, problem-solving process focused on a patient's behaviour (disability), with the following components: assessment - the identification of the nature and extent of the patient's problems and the factors relevant to their resolution; goal setting; intervention, which may include either or both of (a) treatments, which affect the process of change, and (b) support, which maintains the patient's quality of life and his or her safety; evaluation - to check on the effects of any intervention. Outcome The rehabilitation process aims to: maximise the participation of the patient in his or her social setting; minimise the pain and distress experienced by the patient; minimise the distress of, and stress on, the patient's family and carers.

The definition of Wade et al. outlines the structure necessary for rehabilitation. The emphasis is on the existence of a multi-disciplinary, multi-agency team who can assess and treat most of the problems commonly faced by individuals.

The process of rehabilitation is one of assessing (collecting and interpreting data), setting goals, intervening to provide support, enabling self-management potential and treating, then re-assessing to compare the situation after intervention. At some point, the individual should exit this cycle and manage his or her own condition, but there will continue to be times when interventions from the multi-disciplinary, multi-agency team will be required.

The intended primary outcomes of rehabilitation are related to maximising individuals' participation in society.

Elements of the King's Fund and Wade et al. definitions have informed the development of the delivery framework, which has pursued a patient-focused approach to the rehabilitation journey.

Levels of management in the rehabilitation process

Three levels of management have been identified in the rehabilitation process.

• For the majority of people, self management has been shown to be effective in improving quality of life and promoting appropriate use of services.
• People with less-complex needs and their carers are offered condition management support through multi-disciplinary primary care teams, with specialist rehabilitation as appropriate.
• For the small number of people with the most complex needs and their carers, the aim is to offer case management, often in the form of community or specialist nursing, but also capable of being provided by a variety of multi-disciplinary, multi-agency team members. Individuals with complex needs are most likely to be at risk of admission to hospital and may become ill unless their needs are anticipated and addressed. The case management approach should be utilised for individuals in all three of the target groups identified in Chapter 4 who have complex rehabilitation needs.

These levels of management are described in more detail in Box 3.2

Box 3.2 Levels of management in the rehabilitation process

Self management relates to individuals taking responsibility for their own physical and emotional health and well-being and includes staying fit and healthy, taking action to prevent illness and accidents, using medicines appropriately, seeking prompt treatment for minor physical and emotional ailments and self managing long-term conditions appropriately. Condition (sometimes referred to as 'disease') management has been defined as: a system of co-ordinated health care interventions and communications for populations with conditions in which patient self-management efforts are significant.18 Case management has been defined as: a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes.19 Care management is the process of tailoring services to individual needs. Assessment is an integral part of care management, but it is only one of a number of core tasks that make up the whole process. Care management is a cyclical process in which needs are assessed, services are delivered in response and needs are then re-assessed, leading to a changed service response. 20 Case management is the term most often used by health care professionals, and care management is commonly used by social work professionals. As the definitions show, however, they both in essence describe the same service. For the purposes of this document, case management is adopted as the preferred term to reflect the focus on enablement (as distinct from the provision of 'care' services) that is central to this delivery framework.

Creating the vision

A major transformation in health and social care services is now needed to place rehabilitation at the heart of service delivery and ensure that the challenges of the inevitable transitions in the rehabilitation journey are acknowledged and well handled. This means challenging current organisational structures and staff roles.

To do this, we need to move away from a reactive, unplanned and episodic approach to service provision, particularly for individuals and carers with complex conditions and high-intensity and/or ongoing needs. Services are in place to help people and their carers during times of crisis, but the ongoing co-ordinated support and rehabilitation necessary to prevent crises may be less easily accessible.

Evidence shows that intensive, ongoing and personalised case management can improve quality of life and outcomes for individuals with complex or ongoing needs and their carers. This dramatically reduces emergency hospital admissions and enables patients who are admitted to return home more quickly with a co-ordinated support package that will allow them to remain at home as long as possible. The model for rehabilitation which follows aims to ensure planned, continuous rehabilitation support is available within community settings to maximise self-management potential and minimise the risk of hospital admission and readmission.

Developing a model for future rehabilitation services

The model reflects closely the main messages transmitted by individuals and carers during the consultation. These highlight the need to:

• develop person and carer-centred rehabilitation services;
• create direct access to rehabilitation services, where appropriate;
• create a single point of access to rehabilitation services, where appropriate;
• promote a focus on maximising individuals' autonomy and enablement;
• provide rehabilitation services closer to individuals' homes, when appropriate;
• encourage multi-disciplinary, multi-agency teams genuinely to work together in whole-systems approaches;
• adopt a holistic model of rehabilitation encompassing physical, psychological, emotional and social needs;
• strengthen the Single Shared Assessment system on accessing services;
• provide the same quality of treatment for all, regardless of class, age, culture or geographical location;
• review and analyse outcomes on an ongoing basis, with a particular focus on feedback from individuals and carers.

Figure 3.1 identifies the components of a future model of rehabilitation. It is a generic model intended to be relevant for all three target groups identified by Delivering for Health¹ and discussed in Chapter 4.

The future model for rehabilitation identifies, first, opportunities for early intervention for the self-management group, where the emphasis is on self management and health promotion utilising community culture and leisure centres, lifelong learning opportunities and voluntary agencies' services. This phase of the rehabilitation journey could be called 'prehabilitation', or even 'habilitation', and has strong links with anticipatory care.

Figure 3.1 Future model for rehabilitation

The next phase is the condition management phase, into which an individual can self refer when appropriate to a rehabilitation team via a single point of access to enable specific needs, either social or health, to be addressed. It is anticipated that more appropriate and better co-ordinated management in this phase will lead to reduced hospital admissions. If hospital admission is necessary, rehabilitation teams with case managers in place in hospital and community will facilitate safe and effective discharge. Individuals requiring uni-professional interventions should be able to access them within multi-disciplinary, multi-agency rehabilitation teams, ensuring individuals and carers receive the services they require and are not excluded due to restrictive referral criteria.

The model then addresses the need for acute, transitional and long-term rehabilitation services with the aim of ensuring that individuals can access the service at any point, whether through the acute service or by direct access through a community rehabilitation team.

In the acute phase, vital specialist interventions are undertaken by hospital rehabilitation teams with the aim of stabilising the patient and ensuring a timely, seamless discharge process. There will be a continuing need for specialist acute rehabilitation services across Scotland.

The model reflects the need for smooth, planned transitions from hospital rehabilitation to the community, emphasising the importance of working with carers. The aim is to have a flexible service that facilitates seamless transitions across primary and secondary care and encourages joint working. There is good evidence that outreach services following discharge should follow the case management ethos (see Box 3.2, above). There is also scope for developing inreach ^A services to ensure transitions are managed effectively, consequently preventing delayed discharge.

The longer-term rehabilitation phase calls for community rehabilitation teams to work in partnership not only with acute rehabilitation teams, but also across all health, local authority, ^B independent and voluntary sectors and, crucially, with individuals, carers and communities.

The overall aim for rehabilitation services should be to build on the strengths of existing services in these phases to develop a network of rehabilitation teams. Some of these teams will specialise in specific conditions or interventions and others in longer-term involvement with individuals and carers in the community, enabling return to work or education where appropriate and promoting increased social participation.

A separate model specifically relating to vocational rehabilitation is shown in Figure 3.2. Vocational rehabilitation has particular characteristics which justify an alternative approach by services. The aims of vocational rehabilitation are set out in Chapter 4.

Figure 3.2 Future model for vocational rehabilitation

The model for vocational rehabilitation outlines the support structures that should be available to individuals in workplaces to promote health and well-being at work. It then identifies a rapid-access referral process through which individuals should be able to secure support and specialist advice from a dedicated vocational rehabilitation team consisting of a range of professionals (including those shown in Box 3.3) using case management approaches (for a discussion of case management approaches, see Box 3.2).

Box 3.3 Vocational rehabilitation teams
Teams are likely to consist of a range of professionals, including: case manager (any discipline) counsellor manual handling trainer occupational health adviser occupational health physician occupational therapist physiotherapist psychologist support worker. The list is not exhaustive.

Supporting the future model for rehabilitation

The model will require the development of multi-disciplinary, multi-agency rehabilitation teams with a suitably trained and skilled workforce to deliver services that are locally based and patient focused and which adopt an integrated, seamless approach to delivery.

The ethos of the rehabilitation model is about enabling maximum physical, psychological, emotional, social and occupational potential of the individual and improving quality of life. Individuals and carers told us that quality of life is about more than the ability to perform basic activities of daily living, commonly a central focus of rehabilitation, especially in the early phase. The ability to perform basic activities is, of course, important, but is secondary to the need to enable social engagement and purposeful occupation, which are key to encouraging a sense of self worth and well-being and which have been particularly prominent in rehabilitation offered within mental health services. More effective linking between specialist rehabilitation, vocational rehabilitation and community-based social and leisure services is therefore a prerequisite to enhancing the model's effectiveness in practice.

During the process of developing the delivery framework, strong support for the inclusion of individuals and carers in rehabilitation teams was expressed. The intention in developing their contributions in this way is to enhance, and not diminish, the professional rehabilitation services provided to individuals. The aim is to reduce the burden on carers through strategic developments and service delivery that acknowledge and support carers' central role. Professionals should continue to provide key services, education and support at all stages of the rehabilitation process, resulting in individuals and carers being better supported and equipped to play their part in contributing to the design of their own support.

Rehabilitation teams should therefore foster an inclusive, partnership approach with individuals and carers and should include a wide range of health and social care professionals and the voluntary sector (including those shown in Figure 3.3 - the list is not exhaustive). Rehabilitation teams will be working within a diverse range of settings, including those shown in Figure 3.4 - again, the list is not exhaustive. The range and diversity of agencies, teams, individuals and settings involved in rehabilitation services will provide an enormous source of strength and expertise from which patient-centred services can be developed.

Figure 3.3 Personnel within rehabilitation teams

Figure 3.4 Settings in which rehabilitation teams work

Joint induction and training programmes among agencies, which involve individuals and carers, will be needed to develop this team approach. Information and training for individuals and carers about how to contribute to managing their conditions will also be vitally important for successful outcomes.

The role of community health partnerships in supporting the model

In developing the future model for rehabilitation, the model for vocational rehabilitation and the delivery framework recommendations (see Chapter 5), it was important to consider the role of community health partnerships ( CHPs), bearing in mind that CHPs will continue to develop services according to local need and priority. CHPs play a key role in planning and providing NHS and related services for people requiring rehabilitation in local communities. They are local service-delivery mechanisms through which health improvement and shifts in the balance of care are being delivered by the NHS, local authorities and the voluntary sector, with greater involvement of individuals, carers, staff and independent contractors.

CHPs are fully involved in local NHS strategic planning, priority setting, decision making and resource allocation and play a lead role in wider community planning processes led by local authorities. They have delegated responsibility for all primary care and community-based services, including joint health and social care services, community hospitals and resource centres.

Synergies with the broader work being taken forward by CHPs to improve health and care services and health outcomes locally should be taken into account when considering the recommendations. It should be noted that CHPs are already identifying specific and measurable service improvements, according to local needs, in the following areas:

• easing access to primary care services;
• taking a systematic approach to long-term conditions;
• providing anticipatory care;
• supporting people at home;
• avoiding unnecessary hospital admissions;
• identifying opportunities for more local diagnosis and treatment;
• enabling appropriate discharge and rehabilitation;
• improving health and tackling inequalities;
• improving specific health outcomes.

The role of community hospitals in supporting the model

Community hospitals are an important element of health service provision for many communities across Scotland, particularly, but not exclusively, in remote and rural areas. They also have a key role to play in integrated care provision. Delivering for Health¹ cites rehabilitation as one of the elements of practice to which community hospitals can make a significant contribution, and The Strategy for Community Hospitals in Scotland¹⁴ calls on NHS Boards to create the structures necessary to ensure community hospitals remain central to local health care systems. Community hospital services should be maximised to support step-down care from acute hospitals and offer locally based access to services.

The role of intermediate care services in supporting the model

Intermediate care services, which are those that do not require the resources of an acute hospital but are beyond the scope of traditional primary and social care services, have not featured as a key policy driver in Scotland to date. Local partnerships involving health and social services are, however, currently exploring the potential benefits they offer in bringing ongoing rehabilitative and enabling services closer to communities. The Joint Improvement Team is supporting a national Intermediate Care Learning Network which aims to facilitate sharing of good practice and to support evaluation and development programmes with local health and social care partnerships ( www.jitscotland.org.uk).

The role of technology in supporting the model

The national eHealth programme has been launched with the aim of supporting:

• faster access to services through electronic referral and discharge systems;
• enhanced user involvement, with better access to information;
• development of the electronic health record with appropriate security controls;
• sharing of information among professionals;
• development of standardised referral and assessment protocols to support evidence-based care.

Equipment, adaptations, assistive or ' SMART' technology and telehealth will play a significant role in future rehabilitation services. In addition, information technology ( IT) developments are continually extending the range of devices available to support rehabilitation. These offer enormous scope for telecare and telehealth services to support people with health and social care needs to remain in their own homes and to optimise their independence and quality of life.

The National Telecare Development Programme (Box 3.4) was launched in 2006 to lead initiatives in this field. The Scottish Centre for Telehealth was also launched in 2006, fulfilling a Scottish Executive commitment to set up the Aberdeen-based centre to help NHS Boards to make the most of technologies designed to improve health care services. The centre is harnessing the skills and expertise of key groups across Scotland from medicine, operational management and industry to provide advice and support for all parts of the NHS.

Telecare and telehealth could each be pivotal in bringing equality of care to rural areas, preserving, maximising and spreading the benefit of centralised expertise.

Box 3.4 National Telecare Development Programme

The programme makes funds for telecare developments available to health and social care partnerships across Scotland. Partnerships' proposals for funding must: be endorsed by community planning partners; present a strategic approach that demonstrates how telecare will complement the range of other local health and social care services; indicate the scope and range of services to be introduced, with explicit targets relating to impact; provide evidence of how services will be sustained and further developed through the partnership's own resources; provide evidence of the efficiency savings to be gained as a result of the introduction of a range of telecare services. Source: http://www.jitscotland.org.uk/action-areas/themes/telecare.html