Agenda item

Intermediate Care and Re-ablement Project

Anne Marie Lubanski, Strategic Director Adult Care, Housing and Public Health


Councillor Roche, Cabinet Member, Adult Social Care and Health, stated that Intermediate Care and Re-ablement were a key, essential feature of the vision and way forward as they related to independence, choice and living at home.  Re-ablement would be the prime vehicle for moving forward with the approach to localities as it was felt to be the most effective way for services and people.  He introduced Anne Marie Lubanski, Strategic Director Adult Care, Housing and Public Health, and Chris Holt, Deputy Chief Executive TRFT, who gave the following powerpoint presentation on the development of the Intermediate Care and Reablement Outline Business Case:-


What do we mean by Intermediate Care and Reablement – Health and Social Care Services Providing:-

-          Fast Response

Where there was an urgent increase in Health or Social Care needs which could be safely supported at home

Typically 48 hours but may be up to 7 days

-          Home-based Intermediate Care

Including therapies, nursing, equipment and Social Care to support rehabilitation and recovery

-          Bed-based Intermediate Care

Where needs wee greater than could be delivered at home but consultant-led care was not needed

-          Reablement

To help with learning/re-learning skills for every day living, delivered at home


Why Change?

-          People have told us

They would like to be at home wherever possible

They would like to regain their independence

Current services were disjointed and could be hard to navigate

-          Care Quality

Evidence shows people did better at home

We know that a large number of people received care in a community bed when they could have gone home with the right support

Rotherham had significantly more community beds than other similar areas

Current services were focussed on older people and their physical needs

Through changing the way we worked, more people were going home and our community beds were not fully utilised


Current Services

-          Community-based Services

Integrated Rapid Response (TRFT)

Community Locality Therapy – urgent (TRFT)

Independent and Active at Home Team (TRFT and RMBC)

Reablement (RMBC)

-          Bed-based Services

Intermediate care at Davies Court and Lordy Hardy Court (RMBC and TRFT)

Oakwood Community Unit (TRFT)

Waterside Grange (Independent Sector)

-          Services currently provided by a range of teams and bed-based sites

-          In addition, several teams of Social Workers and therapists working into the bed-based provision

-          People moved through multiple services rather than an integrated pathway

-          Significant duplication and some capacity issues in a number of services


Project Aim

-          Referrals

-          Co-ordination

-          Integrated Intermediate Care and Reablement Service

Pathway 1:  Integrated Urgent Response

Pathway 2: Integrated Home-based Rehab/Reablement

Pathway 3: Integrated Bed-based Rehab/Reablement

-          To simplify current provision to provide an integrated, multi-disciplinary approach to support individual needs across Health and Social Care

-          To re-align resource to increase support at home, reducing reliance on bed-based care


Future Services

Community-based Pathways

Bed-based Pathway

1. Urgent response (integrated team)


3.  Community bed-base – rehabilitation and reablement without nursing (integrated team)


2.  Home-based reablement and rehabilitation (integrated team)

3.  Community bed-base rehabilitation and reablement with nursing (integrated team)

-          3 core integrated pathways

-          Services aligned to work as a single team to provide the 3 pathways

-          Increase in community capacity to meet the demand to support people at home (urgent response or rehabilitation/reablement)

-          Reduction in community bed-base (phased and double-running for a period with increased community capacity)

-          Integrating processes for triage and co-ordination to ensure people get the right support

-          Reduction in duplication




Patients and Carers

Commissioners (CCG and RMBC)


RMBC (Service delivery)





Improved experience of services

Telling story once

Reduced duplication and hand-offs

Improved outcomes

More people able to be supported at home

Supports Rotherham Plan for ‘Home First’ and integration of Service delivery

Reduces over reliance on bed base where Rotherham was an outlier

More cost effective model

Supports delivery of the Council’s target operating model and future sustainability

Improving flow through the Social Care system

Supports the Trust’s wider plans for bed configuration/estate moves

Improving flow through the Hospital and Community Services



-          January, 2019 – Scoping

-          February, 2019 – Develop proposal/engagement

-          March, 2019 – Develop and draft proposal

-          April/May, 2019 – Finalise and approvals

-          May/June, 2019 – Approvals

-          June/July, 2019 – Engagement, detailed proposals and implementation


Discussion ensued with the following issues raised/clarified:-


·           Intermediate Care and Reablement was one of the priorities of the Urgent and Community Care Transformation Group, which was jointly chaired by Chris and Anne Marie giving a fully joined up Health and Social Care oversight


·           It was envisaged that as the Service was developed it would be for people 18+ years of age


·           More people chose to go home and the community beds were not fully utilised


·           The services that existed were good; it was not because they were bad that they were being changed.  There was a lot of skill and capacity in the system but the aim was to try to create more capacity and by getting the right pathways; there was confidence that it would deliver the right thing for individuals.  The co-ordinating and alignment of the teams was critical and the right ethos.  There were good services but slightly disjointed in how they operated across Health and Social Care. 


·           In terms of GPs within the model, the Urgent Response Team would have a direct line and communication link to GPs.  The Intermediate Care bed base model would be supported by GPs as it was today but, when aligned, there would be GP input and medical leadership from GPs.  There would be greater clarity on step up and down with GPs having more options to avoid sending people to the Emergency Department.  Through the Transformation Group there was strong GP representation on the model who were supportive of the business case and approach being taken


·           Increased Community capacity would consist of additional Reablement Officers and changing the way people worked, with a focus on therapy rather than rotas and optimising digital.  Additional staff would be required whilst the pathways matured and the first year would be very much one of proof of concept.


·           The business case was still in draft form; until it was signed off responses could not be given to the detail of the project and the presentation was on the direction of travel.


·           Re-admission rates were tracked and Rotherham was in the upper quartile of getting patients back into the right location.  The Integrated Discharge Team, consisting of Health and Social Care teams and therapists, were the gate keepers of anyone leaving hospital as to where they would go.  The development of that Team was one of the enablers to seeing more people getting back home.  The Team had been shortlisted for a national award for the work they had carried out


·           It was not just a hospital pathway and about someone leaving hospital but about people having a change in their life at home and reablement and intermediate care may be appropriate for them.


·           In terms of patient/carer voice in decisions about care, staff would ascertain people’s outcomes of what they wanted to achieve by the intervention.  A lot of the principles that were built into the new proposal were based on the recovery from mental health and the principles tied into that; there was strong evidence in terms of people believing that they could recover


·           Reablement linked in with use of technology/equipment rather than providing care and it was a question of developing confidence and changing the mindset and expectation of people.  It was a journey for people, including for health and social care staff.


It was noted that Anne Marie and Chris were meeting with the Rotherham Clinical Commissioning Group (RCCG) later that day to consider the next draft of the business case.  It was hoped by the end of May 2019 it would be signed off.


Resolved:-  (1)  That the presentation be noted.


(2)  That the principles of the final business case be submitted to the June meeting of the Select Commission.  

Supporting documents: