Rehab on track: community rehabilitation best practice standards

1. Referral processes are explicit, easy, efficient and equitable

Key themes (a) Self referral (b ) Single point of access (c) Population identification and segmentation (d) Minimising health inequalities.

Patients

When I need rehabilitation:

• My GP can refer me
• I can refer myself by contacting the service directly

I know how to do this because:

• There is a service directory that tells me who and how to contact the service

I know when to do this because:

• My health care practitioner has explained this to me

The clinician

There is a rehabilitation directory that contains the information I need to refer a patient to the services they need.

If I am co-ordinating the rehabilitation, I can provide the means for the patient to contact me directly

At discharge, I provide the patients with a written rehabilitation plan which includes:

• Self management advice
• How to maintain or progress function
• Contact details for any next steps in the rehabilitation journey
• Triggers for review
• Routes to review.

The director

• I provide a directory of rehabilitation services.
• I ensure the information that specifies the self-referral pathways is easily available.
• I ensure rapid and skilled triage of patients at the point of entry.
• The clinicians I manage set their appointment times so that they can support patients to self-manage, including learning how and when to self-refer.
• I work within the rehabilitation network to ensure that the written and online material meets the needs of the local community.
• I work with the rehabilitation network and social care providers to ensure that when a patient who is receiving social care is referred for community rehabilitation the social care provider is informed.
• I ensure equity of access and provision.
• I monitor referrals to ensure that underserved populations are not neglected.

The network

The rehabilitation network works with patients, carers and local communities as partners to determine how referral pathways can be disseminated effectively to those that may need to access rehabilitation services.

The rehabilitation network establishes systems that ensure that when a patient who is receiving social care is referred for community rehabilitation the social care provider is informed.

The commissioner

• I have completed a joint strategic needs assessment for rehabilitation services identifying current inequalities in access (and outcomes and future potential demand).
• I ensure the commissioning process includes monitoring of underserved populations.
• I work with the network and local health care organisations to ensure that inequalities of access are progressively minimised.
• I use population health management information to understand the needs of the local population and therefore ensure resources are appropriately focused.

The social care provider

• I know how and when to make a referral to the community rehabilitation service.
• I am aware of the range of services available to people I care for through reference to the rehabilitation directory.
• I am informed when a community rehabilitation referral has been made.
• I know how and when to contact the rehabilitation service for a person I care for.
• I support people I care for to navigate the community rehabilitation pathway.

2. Rehabilitation interventions are timely, co-ordinated and prevent avoidable disability

Key themes (a) early, comprehensive, biopsychosocial assessment (b) co-ordination of care including (c) information sharing resulting in (c) a clear patient journey.

The patient

When I am seen

• It is by the right person
• It is at the right time
• Everyone I see has all the information from other services that they need.

I know who is responsible for co-ordinating my rehabilitation and how to contact them.

The clinician

A clinician should be able to:

• undertake a needs led, biopsychosocial assessment.
• work with other disciplines when this would benefit the patient.
• share information, including up-to-date investigation, medication and test results across the network easily.
• be aware of local resources, which may facilitate social prescribing and ongoing activity.
• know who is responsible for each aspect in the rehabilitation prescription.

The director

• I recognise the importance and complexity of the care co-ordination role by allowing enough time to be allocated to this in people's job plans.
• I deliver and monitor mandatory training in needs-led assessment and the biopsychosocial model.
• I work to ensure that paperwork and IT systems support interdisciplinary and needs-led approaches including with social care.
• I ensure that information can be shared between systems easily and effectively.

The network

The network should:

• involve multiple providers, including primary, secondary and tertiary care, physical and mental health, and social care providers working together to ensure patients are seen in a timely, and coordinated way.
• engage with providers to ensure information sharing with appropriate governance.
• develop systems that ensure referrals and transfers of care are streamlined throughout the network.
• support collaborative working practices.
• share training opportunities and resources.

The commissioner

• I have walked the ‘rehabilitation pathway’ with all members of the rehabilitation network including patients, carers and local communities as partners to be sure it is timely, efficient and effective for different patient groups.

The social care provider

• I am confident that the people I support receive the right service at the right time.
• Information is shared with me about the person I support; including up-to-date investigation, medication and test results.
• I feel confident sharing information about the person I support.
• I have the information I need to provide collaborative care.

3. Rehabilitation interventions meet patient needs and are delivered in an appropriate format

Key themes (a) person-centred rehabilitation (b) information provision (c) patient activation (d) shared decision making (e) goal-oriented programmes (f) rehabilitation prescription plan.

Patients

I know I have the best rehabilitation for me because:

• I am given information about different rehabilitation options.
• I can discuss these options with the healthcare professional.
• I have time to consider the options.
• I can choose the best option for me.
• My choice of treatment is written down for me in a ‘rehabilitation prescription’.
• I can choose different rehabilitation when needed.

The clinician

I am trained in:

• patient activation
• shared decision making
• simple behaviour change techniques.

I can:

• deliver evidence-based care.
• have the time and skills needed to support necessary change to help patients meet their goals.
• co-produce rehabilitation prescription with patients.
• share the rehabilitation prescription with relevant providers across the network.
• offer patients a menu of different options for their treatment.

The director

I deliver and monitor mandatory face-to-face training in:

• patient activation
• shared decision making
• simple behaviour change techniques.

I work with:

• commissioners, local clinicians and the rehabilitation network to map current pathways, identify service duplications and service gaps.
• local clinicians and the rehabilitation network to develop clear pathways for patients with different needs, including those with multimorbidity, and with options for patients with different levels of activation.
• local clinicians and the rehabilitation network to define and describe those pathways so that clinicians and patients can chose the best pathway for each individual.

I ensure staff have time to provide information, undertake patient activation, and shared decision making, recognising that ‘front-ending’ clinical consultations will save time in the long term.

The network

• The network shares training resources in patient activation.
• The network shares training resources in shared decision making.
• The network supports the service to implement best practice recommendations and deliver evidence-based rehabilitation.
• The network supports the integration of research into practice.

The commissioner

• I work with the Rehabilitation Director, local clinicians and the rehabilitation network to map current pathways, identify service duplications and service gaps.
• I have considered levels of patient activation when analysing local population needs and designing community rehabilitation.
• I have considered levels of patient activation as part of outcomes-based commissioning.

The social care provider

• I have the information I need to understand the different rehabilitation options that are available to the person I support.
• I operate within a multidisciplinary team and understand the roles of the other team members.
• I can support people in their decision making around the rehabilitation that best meets their need.
• I have a copy of the rehabilitation prescription for the person I support and am confident to support its delivery.
• I have the time and skills to support people to engage in their rehabilitation.

4. Rehabilitation pathways should meet needs and be delivered locally with access to specialist services

Key themes (a) needs-led rehabilitation (b) integrated services (1⁰, 2⁰, 3⁰ health and social care, physical and mental health) (c) locality based care (d) access to equipment (e) access to specialists and specialist services.

The patient

• I have co-ordinated support for both my physical and mental health needs.
• I am seen locally, where possible.
• When the service I need is not available locally, I am referred onto a specialist service.
• I am able to access the equipment I need and I am taught how to use and maintain it.
• I feel confident to progress my rehabilitation treatment programme as needed.

The clinician

• I know when and how to refer on, and can manage transitions between services effectively.
• I can work with other local services and with mental health teams in a timely and integrated way to ensure the best outcomes for patients.
• I can access advice from specialist services easily.
• I am able to refer on to specialist services when indicated.
• I am aware of and can provide advice about local authority, third sector and other services as well as specialist health services.
• I feel confident to progress/adapt the person’s rehabilitation treatment programme as needed.
• I have access to the resources to support people to progress their rehabilitation treatment programmes.

The director

• I ensure information can be shared, with appropriate governance, between different services and care providers.
• I provide multidisciplinary input to care homes.
• I provide the resources that allow patients to progress their rehabilitation including minor pieces of equipment, short telephone contacts, emails, texts, online support.

The network

• Within the rehabilitation network, specialist services work with place-based services to ensure comprehensive care packages are joined up across the disease trajectory.
• Within the rehabilitation network, commissioners and providers work together to ensure integrated systems.
• Through the network, providers work collaboratively to manage patient needs.

The commissioner

• I ensure that patients can have their needs met, by commissioning local services.
• I recognise that patients may benefit from working with two services over the same period to optimise outcomes.
• I ensure services including health care for the elderly and rehabilitation medicine services are delivered in care homes.
• Where local services cannot meet specialist needs I support ‘provider collaboratives’ and commission ‘out of area’ services.
• Where an individual has highly specialist needs, I ensure that the pathways for commissioning these are clear.

The social care provider

• I support people to attend appointments.
• When equipment is needed
  • I can obtain and arrange maintenance of equipment.
  • I am trained appropriately to support people to use the equipment.

5. Rehabilitation programmes should enable optimisation, self-management and review

Key themes (a) optimisation of function (b) supported self management (c) regular review (d) long term conditions registers.

The patient

• I am helped to do things that are important to me.
• The support I receive seems useful to me.
• I have been told about other services that may be useful.
• I have been given the information I need.
• I know what I have to do to look after my condition.
• I know when to ask for help.
• If I need to be seen again, I know when this will be.
• I have the equipment I need and I know how to use it.
• I know how and when to ask for a review.
• I am confident I will be reviewed when I need it.

The clinician

• I have an appropriate case load, (that allows time to assess patient activation, undertake shared decision making, and goal setting with the patient, and support self-management).
• I have the autonomy to decide the most effective dose of rehabilitation.
• I am aware of diverse social and cultural needs, and am confident in providing effective support.
• I support patients to maintain their independence, and social roles, including work.
• I have the time to work with a patient to support their self-management.
• I am able to work with patients to agree a review date, or when they should self-refer.

The director

• I have the budget to ensure adequate staff numbers, and expertise to deliver timely and effective treatment.
• I deliver and monitor mandatory face-to-face training in supported self-management.
• The service I manage provides generic and condition-specific structured education courses, both digital and face-to-face, including accessible psychological support (within the context of condition adjustment and condition management).
• I ensure the long-term conditions register is maintained and patients are offered annual review.
• I provide practice placements to support the ongoing workforce supply for effective rehabilitation programmes.

The network

• The rehabilitation network works co-operatively, including people with lived experience, to develop supported self-management approaches including health coaching, self-management education and peer support.
• The network shares training resources in supporting self-management.
• The network provides appropriate psychological support within a rehabilitation context and facilitate mental health care where needed (by onward referral) under a matched care and collaborative care approach.
• The network shares/provides training in best practice for the rehabilitation pathways and programmes provided in the system.

The commissioner

• I commission needs-led, integrated community rehabilitation services particularly focusing on:
  • integrated physical and mental health services
  • integrated health and social care
• I commission specialist services with clear access pathways.
• I commission flexible pathways based on patient need, and outcomes focused not level of intervention.
• I commission vocational rehabilitation services.
• I commission services that support self-management including health coaching, self-management education and peer support.
• I commission a long-term conditions register that allows regular review of patients with complex disability.

The social care provider

• I support people who draw from services to do the activities that are important to them.
• I support people who draw from care to receive support that is appropriate for their social and cultural needs.
• I support people who draw from care to feel confident in requesting longer access to rehab if they need it.
• I know how and when to ask for a review for the person I support.

6. Rehabilitation services are well led, adequately resourced and networked to other services

Key themes (a) audit, service evaluation and research (b) defining core data, (c) linking data collection to service development.

The patient

• I have been asked to complete questionnaires that record my rehabilitation progress and goals.
• I have opportunities to discuss my progress towards my rehabilitation goals.
• Providing feedback is easy.
• I know how my feedback is used.
• I can see how feedback is used in ‘you said, we did’ communications.

The clinician

• I have regular clinical supervision, to support my role delivery.
• I collect data as part of my job plan, including PROMS, PREMS, patient goals and service activity.
• I am aware of audits and service evaluations running in my department.
• I am expected to contribute to audits, service evaluations and quality improvement initiatives.
• I understand where the data I collect is sent.
• I understand how the data I collect gets used because there is regular feedback.
• There is a blame-free culture, which allows me to acknowledge and learn from errors.

The director

• I ensure the appropriate governance of the community rehabilitation service.
• I conduct audits and benchmark my services against similar services elsewhere.
• I identify service priorities and link, collate and review data to these.
• I ensure staff are aware of the data analysis and how this feeds into service design.
• I ensure that the information system is appropriate and sufficient to gather and review information on rehabilitation services in order to monitor quality and outcomes.
• I support a learning culture around compliments, complaints, adverse incidents and SUIs.

The network

• The rehabilitation network works with patients, carers and local communities as partners to help design services that address unmet need. The network links with the AHSN and other networks to support with service development and design.
• The rehabilitation network provides mechanisms for sharing good practice and audit findings across the network.

The commissioner

• I define the core data set and determinants of success on which to evaluate the service provision.
• I benchmark the rehabilitation services and commission for progressive improvement in patient access, experience and outcomes.
• I commission the development of data collection processes for underserved populations.
• I support services to apply for innovation funding.
• I support the development of data sets for rehabilitation that offer live feedback and comparisons with national systems.

The social care provider

• I can support people drawing from services to access opportunities to discuss their progress towards their rehabilitation goals.
• I can support people who use services to feedback at appropriate points during their rehabilitation services.
• I am aware of different ways to feedback (verbally, in writing, online, through questionnaires).

7. Rehabilitation services involve families

Friends and family

• I am made welcome at my family member's appointments.
• I have the opportunity to ask questions.
• I am involved in the development of the rehabilitation plan.
• I can choose how much I am involved in the care and treatment of my family member.
• I am trained in the use of equipment that is provided.
• I know where to go for support, (practical, emotional, financial, condition specific), either through the voluntary sector or statutory services.
• I have the opportunity to feedback about my experience with the service.

The clinician

• I am able to identify which patients rely on carers.
• I encourage families to attend appointments.
• I encourage families to ask questions.
• I am able to include education and training of carers/family in interventions, that optimise generalisation of skills for the patient in their usual environment.
• I involve families in the development of the rehabilitation plan.
• I enable the families to have shared knowledge and expectations of rehabilitation.
• I am confident in engaging carers in the rehabilitation treatment plan to enable its successful implementation.
• I make sure families are familiar with and confident in the use of any equipment that has been provided.
• I can recognise when families need support and refer to specialist services when needed.

The director

• I have developed pathways to support families.
• I monitor the experience of families by obtaining feedback.

The network

• The rehabilitation network works with patients, carers and local communities as partners to help design services that meet the needs of families, friends and carers.

The commissioner

• I commission services that support families of people with disabling conditions.

The social care provider

• I keep families informed about changes in function.