Transforming services
Early Intervention and
Prevention
an Integrated Team
Including Occupational Therapy led
Outstanding CQC Reablement
service:
Assistive Technology: Sensory:
Julia McGowan BSc(hons)MSc
Confident Place, Confident People.
Introduction
• The journey from stand alone services to an Integrated
team
• Team Make up
• New Roles
• Overview of team roles
• One Front Door for community referrals
• Reablement with care
• Asset based approach “Deal for Adult Social Care and
wellbeing
• Future Developments
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Original Service Delivery
• Originally we were 3 Stand alone services
• A traditional Equipment and Adaptations
Occupational Therapy Team,
• Reablement service,
• Assistive Technology team,
• Sensory rehabilitation team - joined more
recently
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The Journey
• The then Occupational Therapy Manager
was seconded to develop the
Reablement service
• 3 Occupational Therapists were then
seconded to reablement to help develop
and pilot the service
• Providing advice support and training to
the reablement team
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First steps in Integration
• Development of Locality Model.
• The OT team moved into 3 localities along
with Social care teams.
• Realisation of the value of Occupational
Therapy in Adult Social Care
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Integration
• Following a year of planning and
development by the management team
the 3 stand alone services became an
integrated team one team in each locality
• Working closely with Social Workers and
Social care officers
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Team make up
• A Service Manager - Occupational Therapist.
•
3 Locality Team managers with lead responsibility
across the teams for •
1)Occupational Therapy.
•
2)Reablement.
•
3)Assistive Technology and sensory
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New Roles Developed
• Primary Assessor – trained to assess for
Reablement, Equipment and
Adaptations, Assistive technology.
• Early Intervention Co-ordinator –
manages incoming referrals to the
locality, replacing the multiple duty
systems. Screen and allocate cases.
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Locality EI Team Makeup
•
•
•
•
•
•
•
•
Team manager
Advanced Practitioner Occupational Therapist
Occupational Therapists
Primary Assessors,
Reablement Managers
Reablement offices
Reablement support workers.
1 sensory rehab worker
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Overview of the other roles
• Advance Practitioner Occupational Therapist – some line
management and small case Load
• Occupational Therapist – complex cases and clinical
supervision of PA’s and Reablement Managers.
• Reablement Managers - Line management of support
workers, and reablement officers, Manage Rotas'
• Reablement support officer - set up Reablement
programmes for Hospital Discharge and Community.
• Support workers – carryout Reablement programmes
input feedback into Mosaic. (electronic records)
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One Front Door
Community referrals
• Redesign so that all new cases including
requests care are referred to Early Intervention
and prevention. (A few obvious exceptions)
• Reablement to reduce the need for care or
clearly identify the level of care and support
needed following assessment
• Equipment and adaptations
• Assistive Technology
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Hospital Discharges
• Cases requiring ongoing support following
hospital discharge are also referred to
Reablement.
• In April 2017 a Reablement with care service
was developed for people who need a higher
level care and support on discharge.
• Service users can move seamlessly into
Reablement if they have potential to improve
• Or be provided with an appropriate care
package based on assessment if required.
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.
Performance Information
• From April 2016 to April 2017
• 91.7% of service users do not require
ongoing support following Early
Intervention
• 75.7% of service users do not require
long term support following
reablement.
Confident Place, Confident People.
Title here
for adult social care and
wellbeing
Early Intervention an prevention
Wigan Councils Asset Based approach to providing
services
What is the Deal
• The ‘Deal’ for Adult Social Care and Well Being
see’s care as a whole care and support system.
• It means people are viewed as unique
individuals with assets, gifts and talents,
• It liberates the whole workforce to work in
creative and innovative ways
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The bigger picture
Early
Intervention,
Support,
Safeguarding
Community
Knowledge
Officers
Market
development
officers
• Different
conversations
• Exploring
options,
• Sign posting
• Sharing
knowledge
and ideas
• Connecting as
and when
appropriate
• Understand
what’s in the
community
• The
community
Book
• Support front
line staff
• Locality
Based
• Gather and
collate
information re
gaps in
market
• Develop
solutions to
meet the
needs and
aspirations of
Wigan
citizens,
based on
information re
gaps
Community
connectors and
community link
workers
• A paid
Community
Link Worker or
a volunteer
Community
Connector can
provide
buddying
support to
enable
individuals to
participate and
engage in
community
opportunities
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Provider
services
• Having
different
conversations
• Developing
services in a
different way
• Partnership
working with
the
community
• Enriching the
lives of the
people we
work with
Different conversations
Talking about different things
• Conversation about what is important to their lives
• Move away from formal assessment and reliance on forms
Values the whole person and their life story
• Exploration of gifts and talents
• Having an open mind
Taking the time to do it
• It puts you in an amazing position to be able to do this
• We give staff the permission and training to have these
conversations and then go and make a change
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Core Values for
Occupational Therapy
• Asset based /strength conversations are the way we
unlock what it is that engages people’s heart and
minds.
• Staff are encouraged to begin a conversation with a
blank mind not a range of traditional solutions
• Lives are changed because people are connected
with something that has meaning to them.
• The focus on the strengths, gifts and talents, and
occupations that have meaning to the individuals
underpins the core values Occupational Therapists.
• Having the community knowledge, resources and
the permission to be creative makes it possible.
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Wendy’s Story
• Wendy suffers from Cerebral Ataxia which is a progressive illness
affecting her balance, co-ordination and resulting in slurred speech.
She also had neuropathy in her hands and feet..
• She was refer to Early Intervention as she was having difficult using
her bathroom safely
• She lives alone in a rented flat since losing her husband to cancer in
2014.
• Wendy is a qualified nurse, she used to be in the army and has also
worked as a prison officer and ran a bar in Lanzarote with her
partner
• Before she was diagnosed she enjoyed keeping fit and taking part in
sporting activities such as running and going to the gym.
• Wendy also likes animals, especially dogs and occasionally looks
after her friends dog .
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The conversation
• The Primary Assessor spent time talking to Wendy finding out about
her past, what she liked doing and what she would like to be able to
do in the future.
• Wendy told the Primary Assessor that she did not get out very often,
had low mood and had lost her confidence.
• Her family and friends visited but they do not realise that she is
lonely and needed to get out to improve her social life
• The Primary Assessor explained her role and councils commitment
to address social isolation and how we work closely with local
communities.
• Inspiring healthy life styles and some of the activities such as dog
walking and swimming were discussed.
• Wendy was very keen to have the support of the community link
worker to give her confidence.
• Recommendations for adaptations to the bathroom were made
reducing her risk of falls.
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outcome
• Wendy was referred to the community Knowledge Officer
and this resulted in her becoming a volunteer 2 days a
week.
• She has attended leisure walks and been introduced to a
volunteer dog walker.
• Her friends now invite her out rather than just visit.
• She was initially worried about access to the swimming
pool. Her self confidence is now improved with support
from Inspiring Health lifestyles and she is now swimming
on a regular basis
• Her bathroom adaptations are progressing
• Wendy is very happy with the outcome, she wanted help
with her bathing and her life has been transformed.
• Wendy has given her permission to share her story.
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Volunteering at the Leigh
community Cafe
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Benefits
• A streamlined service for the service user.
• All people are given the opportunity to
improve their Health and well being.
• There is a strong emphasis on People
pursing full and active lives in their own
communities.
• Both staff and resident surveys show
increased satisfaction.
• Reablement service awarded
Outstanding by CQC
Confident Place, Confident People.
The Future
• We are now developing an Integrated Health
and social care services that involves
• Social care
• Early Intervention and prevention
• Health Therapists
• GP’s
• Community Matron’s District Nurses
• Public health
Confident Place, Confident People.