Contact & Connect Post Reablement Contact

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THE POST REABLEMENT CHALLENGE

At the point at which service users are signed off as ‘aim achieved’ and their reablement package is complete, evidence shows an increased attendance at GP surgeries and A&E. On top of this, mandatory reporting on where service users are 90 days post discharge (ASCOF 2b), plus wider council metrics are time consuming and often complicated to collate.

GATESHEAD COUNCIL CASE STUDY

Gateshead Council ASC team has around 2,000 service users coming through the reablement pathway every year. Working as part of a council collaboration using automated telephony to support service delivery, Gateshead has co-designed a post reablement service. Aiming to better support both service users and the reablement team, Gateshead created a simple script to ensure people remain safe and well at home, specifically that they are managing to wash, dress, make their food, take their medication, that they have not fallen and other key questions.

In Gateshead, Contact&Connect will call fortnightly and act as a post-reablement ‘safety belt’ to support service users as they regain their independence. Critically where people identify issues, these can swiftly be addressed with the aim of reducing hospital readmission and the cycle back into reablement. All data and feedback – including where there is no response – is available immediately via an easy to access dashboard with an inbuilt, configurable alert system.

Additionally Contact&Connect will undertake a separate call (or send an SMS message) on the 90th day post discharge to report on where service users are to support ASCOF reporting. The ‘90-day’ call service – Contact&Connect: 90 Day Reporting – is also available as a stand alone service.

CHALLENGE

  • High levels of hospital readmission post reablement
  • Unable to identify and intervene in simple cases and stop the reablement cycle
  • Social isolation
  • Resource heavy tracking and reporting process

EXPECTED BENEFITS

  • Hospital avoidance
  • Reduced GP attendance
  • Preventing hospital readmittance
  • Reduced time spent on reporting & tracking patients
  • Signposting to information & community service

Co-designed in partnership with Gateshead Council

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