What actions need to be taken and by who? Hey : Transition Champion Karl Emerson Neurorehab NHS England has to pay for it Complex need Maria Burney Reignite Trusts interests in Transition We can agitate/advocate for transition- be passionate about our jobs 2How can Step-down from the Tertiary Centres to local care be improved? Lisa Kauffman & Rob Boon What currently happens ? Local teams are invited into MDT re discharge Early involvement with discharge Can the process be improved ? Yes How could it be improved ? Access to hospital notes by local teams Joint teaching sessions Local Leads Standards of care for rehab A rehab package for every child Advising what the local team needs to do especially for less severe major trauma Clear discharge plans Clear pathways to community and for them to be clear who they are to interact Wheelchairs communication with local units Knowing who the leads are What actions need to be taken and by who ? Improving the prescription make sure its comprehensive – Need a patient passport Early communication local unit 3What should future rehabilitation services for Children after Major Trauma look like and how should they be resourced ? Nicola Adamson Rachel Greer What do the rehabilitation services for children after major trauma are in place now? Services depend where you live Where the gaps are Rehabilitation Services for Children, are services in the right place? Access to equipment hydrotherapy variable Communication with hospital teams Lack of coordination IT Gaps and Differences in Community Services Some teams look after children with specific conditions some don’t Services that meet the specific of cultural groups Services are not equitable depends where you are Lack of continuity in some services What to be in place and how should it be resourced ? Tariff that follows the patient Specialist Outreach Team A network to drive change Equipment and Wheelchairs Specialist Outreach team Full MDT to include health and Education What actions need to be taken and by who? A network that builds relations Centralised patient held records
What actions need to be taken and by who? Hey : Transition Champion Karl Emerson Neurorehab NHS England has to pay for it Complex need Maria Burney Reignite Trusts interests in Transition We can agitate/advocate for transition- be passionate about our jobs 2How can Step-down from the Tertiary Centres to local care be improved? Lisa Kauffman & Rob Boon What currently happens ? Local teams are invited into MDT re discharge Early involvement with discharge Can the process be improved ? Yes How could it be improved ? Access to hospital notes by local teams Joint teaching sessions Local Leads Standards of care for rehab A rehab package for every child Advising what the local team needs to do especially for less severe major trauma Clear discharge plans Clear pathways to community and for them to be clear who they are to interact Wheelchairs communication with local units Knowing who the leads are What actions need to be taken and by who ? Improving the prescription – make sure its comprehensive Need a patient passport Early communication local unit 3What should future rehabilitation services for Children after Major Trauma look like and how should they be resourced ? Nicola Adamson Rachel Greer What do the rehabilitation services for children after major trauma are in place now? Services depend where you live Where the gaps are Rehabilitation Services for Children, are services in the right place? Access to equipment hydrotherapy variable Communication with hospital teams Lack of coordination IT Gaps and Differences in Community Services Some teams look after children with specific conditions some don’t Services that meet the specific of cultural groups Services are not equitable depends where you are Lack of continuity in some services What to be in place and how should it be resourced ? Tariff that follows the patient Specialist Outreach Team A network to drive change Equipment and Wheelchairs Specialist Outreach team Full MDT to include health and Education What actions need to be taken and by who? A network that builds relations Centralised patient held records
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