Reablement is key to success of adult social care green paper

The adult care green paper’s key message on joint-working has already been taken up to reduce hospital admissions in Devon and help carers in Gloucestershire, writes Louise Tickle

Change may be scary, but radical and system-wide change is what’s coming to the care system. Services must be more joined-up, there must be a wider variety available, and they’ve got to be better and cleverer at meeting people’s needs – that was the message in chapter four of the government’s green paper on adult social care, published last month.

Linking services together to create a truly integrated system of care is seen as key to achieving this. In the vanguard of this is Torquay North Zone intermediate care team – part of the Torbay Care Trust – which is aiming to reduce the risk of hospital stays and readmission.

Although it is staff-intensive and, on the face of it, expensive, the service is proving to be far cheaper in the long run, says Torquay North Zone’s health and social care general manager, Sonja Stefanics.

If someone who is referred to her team is initially assessed as “rehab-able” within six weeks, they’re offered an in-depth assessment. Then comes an intensive level of service from a multi-disciplinary team of occupational therapists, physiotherapists, district nurses, social workers and a community matron.

“The intermediate care team meets every morning to discuss patients,” Stefanics says. “Typically there are 20-30 in crisis who need to be seen immediately.”

Pooling skills

The team will pool skills and contacts to ensure that patients’ individual needs are met swiftly, giving them the best chance to remain independent and ensuring no further deterioration in physical or mental health that could lead to a hospital stay or residential care.

An agreement with local GP practices means that each day one GP does their own admin and triaging from the intermediate team’s office.

This increases the expertise available to the team, who could ask the on-site GP any detailed medical questions as they arise. The team also has access to all GP and hospital databases, further speeding the information-gathering in an emergency.

Effective intermediate care can involve co-ordinating services, says Stefanics. She describes how an 80-year-old woman with a history of stroke fell at a family wedding in East Sussex. After being taken to a hospital outside her home county, she was in no state to return home safely on discharge.

“We got a call from the hospital which had been trying to get her a hospital bed here, quite inappropriately,” says Stefanics. “She needed a maximum care package, but we felt she was rehab-able within the six weeks.

” To make sure she was safe, we found a temporary intermediate care bed in a nursing home, and arranged her transport there. So from the point of her discharge we knew exactly where she was – not always the case in these situations – and could do a detailed assessment.”

Intermediate care

In the next nine days, the team worked with the patient to understand her needs, and went into her home to make sure that equipment was installed. They told her GP and worked with her family and, because she left the nursing home at a weekend, the on-call intermediate care team made a ­welfare check at home.

As part of a continued review, the woman’s equipment and exercise programme were adjusted, and appointments made at the orthopaedic clinic and the neurological team at her local hospital.

A fortnight after leaving the nursing home, she could go shopping with a friend. “That might sound like a typical rehab story, but the alternative – taking up a hospital bed – was inappropriate and costly,” says Stefanics. “If she’d been discharged home, she’d have been unsafe.

“The biggest gain by far is in preventing hospital admissions, and we can demonstrate that. Intermediate care is free to the patient. Is it expensive to us? Yes, but our objective is to keep people at home. If they end up in residential care, that’s £400 a week, or if they’re in a hospital bed, it’s £300 a day.”

Caring for the carers of adult service users is also effective in preventing a drama from becoming a resource-heavy and costly crisis. After a consultation that asked carers what they would need to cope if they could not get home through sudden illness, accident, travel delay or an unexpected work commitment, Gloucestershire Council commissioned a carers emergency scheme.

One call, one number

One call to one number ensures that any carer whose relative has been assessed as needing a high level of care can be assured that trained support workers will arrive within four hours, and will provide free emergency round-the-clock care for up to 48 hours.

“Getting the scheme in place involved working closely with Community Steps [in-house domiciliary care service], Forest of Dean Council, which held the Careline number, and Carers Gloucestershire, which advised on the scheme,” says Louise West, carers planning policy and projects officer at Gloucestershire Council.

“It was hard in advance to estimate the number of call-outs we’d get and therefore to budget for the service, but 314 people have now been assessed as fitting the criteria where it kicks in, and we’ve had eight call-outs since September last year.”

Much of the value, West says, lies in peace of mind for carers, who know that something will be done if they cannot get home. Less stress means less wear and tear on an already stretched and unpaid workforce; it’s the kind of imaginative thinking in advance that prevents a worse and costlier scenario – and is the type of initiative of which the green paper authors would surely approve.

Case study: Reablement score rocketed nearly 40% in six weeks

The Essex reablement service has re-trained care assistants to teach people how to be independent in their own homes. “Long term, this means they require fewer services, and increases the time it will take until they need more support,” says the service’s managing director Mike Walsh

Katherine*, 76, was admitted to hospital with chest pains and dizziness. She was fitted with a cast to her wrist and thumb, after a fall. Previously living independently, she was dependent on help for the simplest of tasks. While in hospital her handbag and house keys were stolen, leaving her shaken and feeling vulnerable.

On discharge, Katherine’s reablement goals were full independence with personal care tasks and the ability to make her own meals.

Perching stools were supplied to support her weight as she carried out a strip wash at the sink and prepared meals in the kitchen. A domiciliary support assistant guided her in both tasks and taught her to change her top clothing by making best use of the limited movement in her weak arm.

Towards the end of the six-week care package she had enough confidence to use the shower, at first with supervision, then without. She felt able to discontinue the package one week early and, with a reablement score of 140, up from 102 at the start, could manage most tasks by herself.

* Name has been changed

This article is published in the 27 August issue of Community Care magazine under the heading Together they cracked it