Intensive and short term emergency support to enable independence at home

Good practice:

Intensive and short term emergency support to enable independence at home

 

SCOTLAND  / Reablement and 24/7 Crisis Care:  NA/2250 8/49

Rehabilitation is a core element in the delivery of the Scottish Executive’s plans to improve the health and well-being of the population of Scotland. It will be instrumental in achieving some of the key national outcomes and targets that have been set for the NHS and local authorities. 

Customer's need

Reablement and 24/7 crisis care service address a need to:

  • Prevent unnecessary acute hospital admission, or premature admission to long-term care.
  • Support timely discharge from hospital.
  • Promote faster recovery from illness.
  • Support anticipatory care planning, and the self-management of long-term conditions.

The solution

Reablement service provides intensive support to enable independence at home. It is designed to help people learn or re-learn the skills necessary for daily living. Which may have been lost through deterioration in health, and/or increased support needs. 24/7 crisis care has been developed as an arm of reablement services. It is designed to provide short-term emergency support. Further avoiding hospital admission, by allowing people to deal with crisis in their own home.

Keys to success

  • Workforce planning.
  • Close working relationships with general practitioners in planning stages.
  • Development of effective performance framework.

The program

Reablement supports early discharge from hospital in the patient’s own home wherever possible. It promotes self-care and management, and the prevention of unnecessary acute hospital admission. Or premature admission to long-term care. The Reablement Service is available to adults who reside within West Lothian, who are assessed as being eligible for community care. It provides initial short term intensive support in order to allow the individual to build upon their skills and abilities. In doing so, they become as independent as possible. This may be, for example, helping them to become independent in meal preparation. Or using a particular piece of equipment or personal care. The focus of the support is determined by needs.

Reablement is the name given to an approach we use in how we assess and support people. The intention being to provide initial short term intensive support in order to allow the individual to build upon their skills and abilities. In doing so, they become as independent as possible.

24/7 crisis care service is a new approach that involves working in partnership with community nursing services. This will provide a 24/7 service for people who are experiencing a health or social care emergency. Helping them deal with the immediate crisis in their own home. 24/7 crisis care service is structured around community GP localities. It aims to provide treatment, and arrange short-term services (up to 5 days) to support people at home. To support this service, the Social Policy Learning & Development department initiated the development of a two-day bespoke training programme. Which included the introduction of mentors to transfer the learning into practice. The training model recognised that reablement is an approach, and not simply a service. The goal was to develop a skilled workforce with an individual approach to customers’ needs. Providing a person-centred outcome, the workforce delivers a focused approach to care. To achieve maximum impact from the development would require culture and system changes at every level.

Contact information

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Lesley Broadley

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Pamela Main

References

  • Maximising Recovery, Promoting Independence: An Intermediate Care Framework for Scotland, 2012 
  • A National Telehealth & Telecare Delivery Plan for Scotland to 2015

Program partners