KEY POINTS

  • Alderson Ltd (Libertas) provides a home based reablement service;
  • People who only need short term support to remain or return home should be referred.

December 2018: This chapter was revised as a result of a local review. In particular, Section 6, Integrated Community Team Health Based Rehabilitation Service is new.

1. Introduction

Reablement is a short term service which is provided to a person to help them live as independently as possible by learning or relearning the skills necessary for daily living. This service is provided by registered nursing and therapy staff, social care, reablement coordinators and support workers who work in teams to provide assessment, goal led therapy and short term support with activities of daily living to assist individuals in regaining previous levels of independence.

2. Reablement Teams

2.1 Home Based Reablement Service

2.1.1 Who should be referred

The home based reablement service is available to people in Lincolnshire who have been assessed by a health or social care professional as having the potential to achieve reablement goals at the point of referral, following crisis, illness or injury.

The team accepts referrals for people who are:

  • aged 18 and older; and
  • resident in Lincolnshire; and
  • in need of short term support to facilitate discharge from hospital; or
  • in need of short term support to remain in the community.

It is very important that you have discussed the referral with the person, and they are happy to accept the service in their own environment.

2.1.2 Who should not be referred

The home based reablement service will not accept referrals for:

  • people on the End of Life pathway and who are unlikely to benefit from a programme of reablement;
  • people needing long term support with no potential for improvement in their level of independence;
  • people who do not consent to referral and participation in reablement.

3. Referring to the Home Based Reablement Service

All referrals should be made by telephone. Practitioners are advised to complete the reablement referral form (internal use only) prior to contacting the service.

If there is no capacity or anticipated capacity within the reablement service, the referral should be made to CSC for an Adult Care assessment.

Home based reablement referrals can be made between the hours of 7.00am and 10.00pm, seven days per week. For details on how to contact the Home Based Reablement Service, see Local Contacts.

4. Referral Route out of Reablement

When someone is approaching the end of their reablement journey and where ongoing care needs have been identified:

  • the home based reablement service will email the referral, via secure email, to the business support officers in each area team;
  • the business support officer will then ensure the information is recorded in the person’s file and forward the referral to the appropriate area team;
  • the lead practitioner will review the referral:
    • if the lead practitioner judges that the assessment does not evidence eligible needs, they will return the assessment to the reablement service so the person can be signposted to appropriate support;
    • if the lead practitioner judges the assessment to evidence eligible needs, they will allocate it to a practitioner for immediate completion of a support plan based on the reablement service’s assessment;
  • the practitioner will send the support plan to Brokerage for procurement of support pending the full Adult Care assessment and Personal Budget being in place.

5. Adult Care Processes

The reablement service is not an Adult Care service; recipients will usually not be Adult Care customers unless they are receiving reablement support on top of existing packages of care or where their social circumstances indicate the need for Adult Care intervention (for example, professional support of a social worker) in addition to the reablement services.

Any assessments undertaken by Adult Care practitioners which lead to reablement services being provided will not progress beyond the assessment stage when being recorded in the customer’s Adult Care record.

No information reflecting services provided by the reablement team should be recorded directly in the customer record. However, any documentation received from reablement services should be stored in the customer’s record.

6. Integrated Community Team Health Based Rehabilitation Service

Lincolnshire Reablement Service (LRS) and LCHS therapy services are working closely together. They provide therapy and nursing support for people who are receiving reablement services.

Where appropriate cases are managed together to ensure the individual care plan is joined up. This allows a smooth transfer of information and dialogue between the two providers.

The referral route is still via the reablement process.