Provide a safe and responsive rehabilitation, reablement and recovery service that supports people to regain independence post discharge.

Provide quality care and support to all residents through a person-centred approach, giving full support to moving people on to more permanent arrangements, where moving back to their home is the first option to be considered. It will be essential to embed a reablement ethos into these units using the expertise of physiotherapist and occupational therapists.

• Will not be able to return home directly from hospital, even with community health, social care and/or voluntary sector support
• Will require a period of recovery/rehabilitation/reablement in a 24-hour bedded unit (up to 4weeks) and likely to return home.
• Are medically optimised for discharge and no longer meet the criteria to reside in acute care
• Will have identified recovery/rehabilitation goals that cannot be met in their own homes and have clear outcomes expected following the period of short-term support
• Will consent to admission or if people cannot consent to this then Best Interest Assessment must be completed prior to admission
• Will not require specialist rehabilitation beds e.g., stroke/neuro rehabilitation
• Will not require 1:1 support due to significant cognitive impairment and or behavioural challenges.
• May include those whose needs are unknown but who may not as yet be able to return home.

Estimated LOS (Length of Stay):

• Up to 4 weeks (with some exception that some patients may exceed this timeframe)

Professional/clinical care expectations

Rehabilitation professionals:

• To transfer with a brief therapy plan- functional ability, goals and exercise program if provided in acute
• Therapy initial assessment (Occupational therapy (OT) or Physio) within 24 hours of admission
• Goal setting and therapeutic advice and program handed over to therapy assistants and care home staff- within 72 hours of admission
• Estimated discharge date set within 72 hours of admission
• Access visits and/or home visits to be carried out as required
• Therapy staff to be made available to care homes

Medical care

• GP review (where needed) within 72 hours of admission or ACP- nurse practitioner, access to weekly GP follow up/oversight (in line with existing standards in the enhanced health in care home framework), access to pharmacy (if assessment required before 72 hours, this needs to be highlighted to GP).
• Acute trust following patient discharge would need to send medication for patient on arrival at care home (to ensure no further delays).

Nursing care

• Aligned community nurse linked to beds and/or Enhanced Nursing Home service to provide support (where the care unit is in a care home without nursing registration)

Care home staff

• Therapy team to work with care home staff to support development (and ultimately sign off) rehabilitation/reablement competencies

Social care

• A social worker within 48 hours of admission and initial assessment completed (preferred “allocated staff covering specific care homes/units) and care planning support to ensure timely transfer to the persons home environment

Communication/transition along the discharge to assess (D2A) pathway

• Person to be discharged and family/carers to be updated and included in discussions regarding their care and discharge planning
• Person to be discharged and family/carers meetings to be arranged as required- suggested minimum of once during pathway 2 stay
• Inform person to be discharged and family/carers on where they can find further information on intermediate care. For example the NICE quick guide to intermediate care which provides links to patient groups.
• Weekly MDT meeting to include therapists and social worker
• All professionals involved, the person to be discharged and family/carers to be aware of estimated date of discharge (EDD) and goals for discharge
• Transfer of care leads (transfer of care hubs) manage pathway and are pivotal in determining patients’ needs

Outcomes measured

• Discharge destination
• Length of stay (LOS)
• Patient and carer/family feedback
• Outcomes including any functional outcome measures e.g. Barthel

NHS outcomes framework domains and indicators

Reasons for Admissions

• Joint working within the service and with other agencies and partnerships
• 90% patients with a length of stay (in beds and on caseload) of under 4 weeks
• Training programme in place supporting any care home staff working with people in the care unit.
• Beds to be maintained at 90% or over occupancy
• Beds available for the person to be transferred into on the day they no longer meet the reasons to reside criteria in hospital – coordinated and manged by the transfer of care hubs in hospitals
• Trusted assessors arrangement utilised with hospital transfer of care hubs, in line with CQC guidance, to avoid the need for registered care home mangers having to assess the person in acute care
• Full MDT assessment to be completed within 2 operational days of admission onto caseload/bed- target 100%
• Individualised goals and care plan to be agreed with patient within 2 operational days of admission to caseload /bed. – target
• 90% of patients partially (at least 50%) achieving their goals
• 90% patients assessed using a validated clinical outcome measure for rehabilitation tool to be decided by the Provider
• Patient satisfaction existing measures used in your system. (i.e. FFT- Friends Family Test)
• Operational day defined as Monday to Friday.

• To promote activity, increase strength, endurance, independence and ability to manage activities of daily living by providing access to therapies with a focus on restoring function.
• These include functional practice opportunities, wellness and self-care activities that support the return of patients to their previous living environment or other appropriate community environment.

Pathways

• Overall pathway- the general flow of service users is illustrated in the diagram below.

{INSERT flowchart}

Essential Service Components

The Provider shall

• Provide access for MDT staff to the recovery/rehab/reablement beds and provide full time short stay person centred care for referred clients
• Ensure the rooms will be made available for admitting clients 7 days a week, during the contract period, including bank holidays. Admission times will be dependent on the needs and safety of each individual and are expected to be within 8am – 6pm to facilitate timely discharges
• People who are eligible for care will have varying levels of dependency and are likely to have both physical and low level mental health needs. The Provider will be expected to always have suitable staffing levels available to meet these needs.
• Not restrict access to the beds, unless there have been emergency restrictions
  placed upon the home by CQC
• Comply with all Department of Health and Social Care, UK Health Security Agency and Care Quality Commission requirements where infection control measures are required
• Ensure outcomes specified within an individual’s care plan are met
• Ensure that care is delivered in a manner which will maximise the independence and wellbeing of the client
• Admit clients to the facility on the day they no longer meet the reasons to reside criteria in hospital – coordinated and manged by the transfer of care hubs in hospitals
• Use the trusted assessors in the hospital hubs to enable the care home manager to fulfil the regulatory requirements to assess the person prior to admission to the care home
• Be required to deliver double assist care. The Provider shall be able to evidence how they will meet this requirement.

Eligibility Criteria

• The service will be provided to individuals with care and support needs who are medically fit in that they no longer meet the criteria to reside in an acute general hospital but would benefit from short term accommodation based care to improve their functioning and to allow for further assessment.
•  Have a physical disability which can be accommodated.
• Admission times will be dependent on the needs and safety of each individual and are expected to be within 8am – 6pm, seven days a week to facilitate timely discharges.

Essential equipment and/or facilities

• People should have mental capacity and not Deprivation of Liberty Safeguards (DOLS).
• Wi-fi access for patients and clinical staff.

Other exceptional requirements

This contract is not suitable for the following:

• Palliative care patients
• Clients who have a life expectancy of 6 weeks or fewer
• An individual who has tested COVID19 positive before discharge, unless the individual has completed the required isolation period and is therefore considered to be no longer contagious
• Planned respite/replacement care.

Links to other key documents

NICE guidance:
Understanding intermediate care, including reablement | Quick guides to social care topics | Social care | NICE Communities | About | NICE

CQC guidance on Trusted Assessors:
20180625_900805_Guidance_on_Trusted_Assessors_agreements_v2.pdf (cqc.org.uk)

• Parallel Walking Bars
• Rehabilitation Steps
• Therapy Couch
• Small equipment required for exercise/rehabilitation