Navigating Rehabilitation
Diana Halliwell
Head of Continuing Care
Central London Community Health Care
Hammersmith & Fulham
H&F Continuing Care Service
Westminster
PCT
Westminster
Ealing SS
SS
H&F
PCT
Ealing PCT
H&F
SS
Hounslow
SS
K&C
PCT
Hounslow
PCT
Hillingdon
SS
Hillingdon
PCT
K&C
SS
H&F Continuing Care Team
Team Administrator
PA/YPD
Head of Continuing Care
Diana Halliwell
Finance Manager
Deputy Head of Continuing
Care
YPD H&F
Assistant Finance
Manager
Health Care Manager
YPD K&C/Westminster
Information Manager
Health Care Manager
YPD Hillingdon
Health Care Manager
YPD Ealing/Hounslow
Older People Health Care
Manager
Mental Health Care
Manager
Health Care Assessor
YPD
Older People Health Care
Assessor
Mental Health Assessor
Team Administrator
Older People/Mental
Health
Aims of Service
►
►
Case Management from acute care through NHS or
independent sector rehabilitation and into continuing care;
Making optimal use of resources to facilitate recovery and
care by:
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





facilitating discharge from hospital
avoiding admissions to hospital and residential care wherever possible
ensuring access to rehabilitation where necessary
complementing personal & social care packages offered by social
services
co-ordinating access to health services where a range of professional
expertise is required
increasing the flexibility of available health services and choices
offered to clients
offering comprehensive tailor made continuing health care packages
for clients meeting Continuing Care Criteria
ensuring cost effective service provision
Referrals
Westminster
K&C
H&F
Ealing
Hounslow
Hillingdon
The Workload
Pending Cases
Continuing Care
Care Pathway
Acute Care/Neurosurgery
Ward-based Therapy
Goals and
Reduced
measures
of
outcome
impairment and
pathology
Post-acute inpatient
Specialist rehabilitation
HOSPITAL
Improved activity
(reduced disability)
hOME
Community-Based Rehabilitation
Day Centre
Out-reach/home based –
Vocational Rehabilitation –
Enhanced
participation
Longer term Community Support
Specialist Case Management
Maintenance of gains
Review/drop-in clinics
Re –access as required
Hole Systems !
►A
pathway full of
potholes
 The transition from
acute to rehabilitation to
continuing care never
did run smooth
Complex Specialist
(Tertiary)
NW LONDON NEURO REHAB
RESOURCES
*RRU
Northwick Park
*BIRU
Edgware
RNOH Stanmore
Pain Rehab
SCIU
*Queen Square
(N.Central)
*RHND
(SW)
Other Services
Wolfson
Frank Cooksey
Blackheath
Homerton
District Specialist Rehab
Alderbourne Unit
In and Out patients
(Mostly Hillingdon)
Robertson Centre
Willesden Community Hospital
(Brent)
Neuro Rehab Unit
Charing Cross
(All PCTs)
Out of Contract
TLU – RHND
BDU –RHND
Vent Unit – RHND
St Andrews – Northants
BIRT – Milton Keynes
David Ferrier Unit
Queen Square
(K&C and Westminster)
Local General Rehab
Herrick Ward
Northwick Park
In and Out patients
( Harrow)
Rehab Unit
Royal Free
In and Out Patients
Athlone House
Norton House
In Patients
(Westminster)
Clayponds Hospital
In and Out Patients
(Ealing)
Farm Lane
In Patients
(Mainly H&F)
Community Teams with
Dedicated Neuro-rehab component
Harrow PDST
Includes Neuro-therapists,
Psychology & Rehab Cons.
Westminster CRT
Includes ABI, Neuro-therapist
and Psychology
Brent CRS
Includes Neuro-therapists,
Psychology & Rehab Cons.
Kensington & Chelsea CRT
Includes ABI, Neuro-therapist
and Psychology
Local Community Rehab Service
incorporating Neuro-rehab elements
Hounslow CRT
Includes Neuro-therapists
Ealing ARISE
Includes Neuro physio
Hillingdon CRT
Includes Neuro physio
RRU Specialist Community Outreach Service
•Supports complex disability in the community
including residents of specialist nursing homes
•Working with general & specialist rehab teams
•Specialist interventions e.g. botulinum toxin
Hammersmith & Fulham
CARS
Includes Neuro-therapist
Key
*
*
Main Tertiary Units which Specialised
Commissioning have contracts with
Finding the Right Placement
………
Outreach Epilepsy
Follow-up
Other Services
Psychiatry
Outcomes
Cost
Waiting List
Ventilator Aggression
Oxygen
Clinical needs
Speech Therapy
Locked Unit
Prognosis
Age
Activity
The Locality
The Family
Language
What Do We Want From
Providers..?
The issues
THIS WAY