ECRA – Enhanced Care Recovery is an approach is a Holistic Integrated Approach to support and care. it focusses on people receiving support and care in their own homes or HwC Tenancy’s. The approach encapsulates an integrated, holistic, interdependent approach which is comprehensive to rehabilitation and recovery, based on the “Social Model of Disability”
ECRA – is a community based approach of socialisation which focuses on enhanced support and care that promotes the management of key aspects of an individual’s needs in order to bring about improvements in all aspects of their life by enabling people to retain their independence, control and dignity.
The key delivery plan for this “paradigm shift” denotes a change in how the MDT historically views the infrastructure at the cold-face of delivery. This model of care and support promotes the implementation of the “social model of disability” delivered in an individual’s home within the community and is based on the following aspects to promote and achieve positive outcomes:
- Using the Care Programme Approach (CPA) and Person-Centred Care the team will adopt a comprehensive enablement focussed approach which is aimed at promoting recovery and preventing relapse.
- The aim of this care pathway is to enhance the quality of support and care provided to people living in the community, by improving re-enablement subsequent to extended institutionalisation or hospital stays, whilst promoting their safety and increasing the individual’s opportunities to independent living through optimizing clinical input from within the community.
- Diverse flexible person-centred care planning according to assessed needs from discharge out of hospital into community settings.
- This support approach includes an understanding of the individuals care needs and required relationships to be established prior to finalising the care package for long term determination through a thorough pre admission assessment.
- This Care Pathway includes collaborative working relationships with members of the MDT and Focus Care will liaise with relevant community health teams and or private specialists to implement the relevant person-centred clinical input as required and agreed for each individual.
- To promote seamless transitions and Care Pathways at all times.
Alternative Care Pathway:
- An enhanced discharge from hospitals by facilitating Transitional Placements within a “ Housing with Care (HwC) short hold tenancy or a hub for care in a bespoke registered care home” in the community as appropriate for those people with complex needs who can challenge services.
The purpose of the hub is to established levels of support and care required prior to placement back into the individuals local community of choice or origin which will facilitate the “clawing-back” of out of county placements for those service users with sever and enduring Mental Illness; Learning Disabilities; Autistic Spectrum Disorders; Acquired Brain Injuries; Dementia’s including early onset and Behaviours that Challenge existing services by supporting and enabling people to live closer to families and friends.
- Enable people with complex behavioural needs to identify with their Key Worker prior to a transfer out of the hub to their permanent placements to promote continuity of care and support, build a trust relationship which would impact positively on achieving smooth transitions.
- This methodology will be based on consultation and informed mutual decision- making by the individual and multidisciplinary team to identify the most important elements of care that will be required to maximize recovery and enablement with agreed timelines, as appropriate.
The organisation of the care pathways will include:
- A statement of the individual’s goals and key elements of care based on evidence, best practice, and service user consent.
- The facilitation of the communication, coordination of roles, and sequencing the activities of the multidisciplinary care team, service users and their relatives;
- The daily progress documentation, review and audit of care plans of agreed outcomes.
- Using outcomes based care planning and Tools
- Value for money based outcomes.
Home with Care Placement (HwC) – Domiciliary Care / Supported Living Individuals:
- Re-enabling people back into their own homes or through other tenancy’s from institutional, residential or other bed-based care to home life settings.
- Supporting and involving people to make comprehensive gains which are achieved in an integrated, holistic, person-centred manner through the individuals understanding of their own reality for enablement and recovery.
- Empowering people to make informed choices about their lives and their right to a life which fulfils their personal potential and supporting them to achieve and optimize their level of recovery.
- Working in partnerships with individuals and their families/relevant representatives to achieve the best long-term relationships to develop and enable positive outcomes.
- An inclusive and participative member of society.
Clinical Support and Delivery:
- Utilising the best of Support Workers, Occupational Therapy and Specialist Behavioural Nurses input in the relevant care domain (mental health, learning disabilities, autistic spectrum disorders, physical disabilities, acquired brain injury and behavioural challenges) to program and inform care delivery, which includes developing the level of expertise within the team and support services.
- Embracing innovative change and challenging the status quo by using expertise within the MDT which is privately sourced, flexible, relevant, effective, efficient and responds rapidly to changes in the needs of people being supported which is value for money.
- Investment in training staff that is tailored to the needs of the individual being supported.
- Recruiting the appropriate skill mix and staff that have a positive attitude toward risk taking to achieve excellence in delivering support and care within people’s homes.
- Using outcomes based tools for objective measurement to assess achieved outcomes and preventing relapse.
- Enabling people to recover through consultation and choice by building social, economic and other links to full community participation and being supported to access their rights and entitlements.
- Enable and empower individuals that live in their own homes to achieve their maximum potential for good health and independence through their own perception of well-being and recovery.
Financial Cost of Support and Care:
- Operating a Lower Cost Base than other care, support and rehabilitative models of care to move people from high cost bed-based services back into the community.
- Movement toward a Managed Care Model of payment for achievement/cost effective value for money service delivery.
- Support and care for men and women aged 18 and above in their own individual tenancy’s or shared homes within the community.
- Sever and enduring Mental Illness; Learning Disabilities; Autistic Spectrum Disorders; Acquired Brain Injuries; Dementia’s including early onset and Behaviours that Challenge.
What makes Focus Care Agency and the ECRA different to other providers?
- We are focused on combining enhanced care, enablement and recovery with dedication, offering our service users a flexible, tailored solution to their specific care and support needs within the community based on a social model of disability which is designed to take advantage of their opportunities to recover (As they see and experience recovery).
- We are passionate about helping our service users succeed in developing skills and striving towards independence.
- Our professional service delivery approach combined with our focus and philosophy of care and support is designed to meet our service user’s unique needs because we understand that “one size does not fit all.”
- We invest in training to ensure our staff has the capabilities/skills that allow us to operate our service in a way that delivers low-cost, high availability and an outcomes based services.
- Our policies and procedures include an extensive catalogue of best practice, processes and tools for managing our services.
- We are unique because our service users are the leader’s of the team and we work with purchases to create person-centred care packages which are flexible and comprehensive (holistic, integrated and person-centred) to support each individual’s specific objectives.
- Our mission is not to “re-invent the wheel” but to provide excellence in care and support whilst operating and supporting the social model of disability in a value for money driven manner.
- We can augment existing community health teams or provide a fully outsourced specialist team to support specific needs.
- We provide measurable financial value for the service users and organizations we serve.
- We are service user driven and evidence this in our support and care by allowing the service user to take the lead in determining their own objectives and goals for enablement and what they perceive recovery to be.
- We value people and their decisions by supporting the individual to take the lead in making the changes to their lives to enable them to be fully participant within their chosen communities and have their voices heard.
- Staff leadership enhances the power of expectation “The Pygmalion effect” which in turn enhances service user and staff interconnectedness within the social model of disability.
What is ECRA (Enhanced Care recovery Approach) and how does this impact on Managed Care:
Health care is evolved from an inpatient, acute care, orientated system, ECRA is an approach that emphasizes primary care and the coordinated, interdisciplinary provision of comprehensive enhanced care delivered through a managed-care network that focuses on recovery. This network includes both independent and community based services from the MDT.
Managed care typically implies some type of arrangement whereby a network of providers agrees to deliver a predetermined package of care services to a defined population for a negotiated prepayment e.g. Models of reimbursement are:
- Percentage discount off charges
- Set rates paid per day
- Capitation (Fee per person)
All these models have been used in managed care arrangements in which the provider receives a set amount of money regardless of the services delivered.
The capitated payment approach of ECRA (Enhanced Care Recovery Approach) encourages those who purchase services to become cost-conscious consumers, whereas it forces us as providers of services to compete on the basis of price and quality.
To withstand the parallel financial risks associated with a capitated payment system, both buyers and providers of care services realise that they must form an integrated delivery system across the continuum of care and support delivered within the community.
The goal of managed care is to establish linkages among individuals, institutions and organisations to establish a value driven pattern of care.
A value-driven delivery system strives to be cost effective, it not only lowers costs but it also ensures that consumers receive the most effective care for the least amount of money.
The integrated network dimension of ECRA as a managed-care delivery approach implies that it is the quality of the linkages between members of the network that will propel consumers and providers into cost-effective actions.
Network linkages that promote cost-effective behaviour’s on the part of consumers, payers and providers are in part predicated (exist) on an organisational phenomenon known as coordination. Coordination is the teamwork across individuals, departments and organisations so that the activities necessary for the organisations success do not go unperformed.
Coordination implies collaboration or an integration of comprehensive effort, of which communication among individuals and groups is the basis.
Transforming and achieving equity, by the redistribution of resources and being mindful of a shrinking public sector budget, the Enhanced Care Recovery Approach asserts that an orderly systematic process, based upon sound rationale, applied to determine the number and kind of staff required to provide care and support of a predetermined standard at reasonable cost to individuals in the community.
With the ECRA emphasis on low-cost and effective delivery Focus Care Agency Ltd will have to increase accountability for coordinating care and support with an increasing number of specialists across institutional boundaries and in a way that minimizes and prevents readmission and hospital length of stay while attaining predetermined quality outcomes.
How will Focus Care Agency Ltd improve the coordination of services?
- Through assessment of our practice environment and understanding the nature of the care and support we provide within the community and in people’s homes. We will be in a position to identify – resources, information, relationship needs and consequently, the coordination needs of our consumers.
- Improving the coordination of services requires visible leadership that advocates a team-orientated culture, open communication, empowerment and collaboration while actively modelling behaviours that facilitate teamwork through and even beyond the entire organisation. These management practices will contribute to an environment that values development of coordination mechanisms that effectively link our company across all levels of the purchaser network, minimize uncertainty and enhance efficiency.
- Structural strategies that maximize coordination across network boundaries might include the creation of the following:
- “Direct line” communication channels so that Focus Care Agency can express concerns to appropriate network managers
- Protocols, standards of care and support or critical pathways for the provision of enhanced care and recovery services that focus on re/enablement and independence.
- Six monthly and interim care and support planning review conferences that are attended by the MDT as required.
- Opportunities for face-to-face discussions or group conferences between Focus Care Agency and community care providers for complex service user care situations (Crises Management situations).
- Continuous training of various staff categories which is focussed on service user needs
- Incentives and rewards that recognise innovative team performance and team-related outcomes
- When ensuring comprehensive and substantive exchange of information among network members, providers possess the critical information that will minimise service user uncertainty and promote efficiency.
- Success in a community based setting involves the continuous balancing of the tension between differentiation and coordination of efforts within the unique contingencies of the practice environment. Therefore as Focus Care Agency continues to grow and expand we will move into a variety of managed-care networks, and make our mark as a well-differentiated provider able to deal with the challenges in developing a more effective means for coordinating our efforts. We know that every coordination mechanism put into place may be associated with cost.
Key roles Focus Care Agency Managers will play in delivering ECRA within the community:
- Managers receive training on the philosophy of ECRA (Enhanced Care Recovery Approach) and Outcomes measurement Tools in order that they are able to support staff to achieve effective efficient care and support outcomes.
- It is vital to understand the service users’ needs because of the daily contact staff will have with them – identifying robust training and information relating the service users.
- Providing comprehensive support/care which is focused on enhanced re/enablement, recovery, independence, choice, dignity and respect. Setting new expectations about the delivery of services within communities to individuals in their own homes/Tenancy’s and implies new processes which are service user focussed.
- With this changed approach it is vital that Focus Care Agency staff are trained to participate in the management of care and support with their focus on the diversity within and not on a specific sector of the population with a new and innovative vision of care and support within peoples own homes, residential settings and in tenancy dwellings. Participating actively in reducing acute inpatient stays and re-admissions.
- The leadership role will be focussed on training managers about value for money and the reduction on the cost of a service user’s care and support while improving outcomes.
- Education about these changes will provide the impetus for all Focus Care Staff and managers to challenge the old way of doing things and to play a critical role in the re-engineering effort. We are committed to these changes being made, with the knowledge that the dynamics must be understood and supported by all parties.
Manage the outcomes:
The regional mangers/nurses and team leaders within the service will take a leadership role in delivering care and support because the responsibility of integrating services rests clearly on their shoulders e.g.
- A prospective plan which involves collaborative care and support planning by the Focus Care Agency team, other relevant professionals and the prospective service user will be developed from preadmission to the day of admission and subsequently as needs are identified. At this point consideration of best practice for high-risk challenging behaviour will become a reality and commitment by the staff and service user to make ECRA work. The outcomes will be measured through the use of Outcomes Support Plans and Tool.
- Pre-education programs will be implemented to support staff and enhance understanding of the service user’s disabilities, needs and challenges and therefore reduce readmissions and length of stay in hospitals which will impact efficiency savings.
- Partnerships and collaborative integrated working relationships will be formed by the Focus Care Agency staff team and relevant community teams or private providers of specialist services by utilizing reviews in order that Focus Care staff will have the resources and support necessary to accomplish the job of managing the outcomes, cost and quality issues across the entire course of the service users enhanced enablement to independence and recovery, including those episodes of illness. Ensuring that the entire continuum of care, support, recovery, health and well-being is addressed.
- Develop pathways that create excellence in clinical outcomes within the amount of resources available from the different payer groups.
- In the ECRA quality is very important as a cost-effective measure to delivering care and support because any time spend on rework such as service user placement breakdown is costly.
- To empower Focus Care Staff they must have the tools to do the job, this is achieved through education and continued development.
- Focus Care Management must give the staff ownership of their ability to provide care and support within the community and ownership of the quality and outcomes that they as support workers produce.
- Give Team leaders access to the units finances which will empower them because staff can only change when they are aware that they are not performing.
- Is a paradigm shift in thinking by us as a provider regarding how we deliver care and support within the service user communities?
- It is the fundamental rethinking and consequent radical redesign e.g. business processes that will achieve dramatic improvements. Payers and their commitment demand nothing less
- Roles are different in delivering ECRA (Enhanced Care Recovery Approach) and many things are done differently all the old assumptions of how things were done must be challenged.
- Positions must be converted to those that will serve the organization and the service user better in this new environment.
- Culture changes-create a caring vision, develop a philosophy of care and support in people’s homes and within the community.
- Reorganization of support worker training
- Expanded or new roles and functions
- Job category changes by eliminating and creating multifunctional roles
- Who takes the lead within the multi-disciplinary team at the relevant point in time
- Technological support
- Decentralization changes
- Expand service user care and support programs by being creative and innovative.
- Consulting, giving people choices and valuing the voices of those that purchase care and support.
The Enhanced Care Recovery Approach (ECRA) – concentrates on providing the basics of support and care well, and consistently well, whilst utilising behavioural technics to identify the motivational fuse needed to bring about improvement in an individual’s ladder of change.
This approach uses socially acceptable methods and technology made universally acceptable to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their support/care pathway to reablement and independence in the spirit of self-reliance and self-determination.
1. Social Model of Disability – Models of disability provide a framework for understanding the way in which people with impairments experience disability. They also provide a reference for society as laws, regulations and structures are developed that impact on the lives of disabled people. There are two main models that have influenced modern thinking about disability: the medical model and the social model.
In the medical model, disabled people are seen as the problem. They need to change and adapt to circumstances (if they can), and there is no suggestion that society needs to change. This model reflects the World Health Organization definition of disability.
The social model has been developed by disabled people. In their view disability is caused by the barriers that exist within society and the way society is organised, which discriminates against people with impairments and excludes them from involvement and participation. This model reflects the Union of Physically Impaired Against Segregation (UPIAS) definition of disability.
The social model of disability is not a traditional diagrammatic model like many psychological and sociological models, but a progressive political concept that opposes the medical model commonly used within the health professions.
The Social model of disability makes an important distinction between the terms impairment and disability.
- Impairment – Lacking part or all of a limb or having a defective limb, organ or mechanism of the body (including psychological mechanisms).
- Disability – The restrictions caused by the organisation of society which does not take into account individuals with physical or psychological impairments. (UPAIS, 1976)
This distinction is embedded in social constructionism (a philosophical foundation of the social model), which states that these terms differ in that impairment exists in the real physical world and disability is a social construct that exists in a realm beyond language within a complex organisation of shared meanings, discourses and limitations imposed by the environment at a particular time and place.
The social model is a concept which recognises that some individuals have physical or psychological differences which can affect their ability to function in society. However the social model suggests it is society that causes the individual with these physical or psychological differences to be disabled. In other words individuals with impairments are not disabled by their impairments but by the barriers that exist in society which do not take into account their needs. These barriers can be divided into three categories: environmental, economical and cultural (British Council of Disabled People).
The environment disables people by not being accessible enough for them to move, function and communicate as effectively as people without impairments. A great deal of the environment is designed by people that do not have any impairment. For example, a person in a wheel chair is only ‘disabled’ if the environment is not designed for people with wheel chairs. A wheel chair friendly building would probably include ramps, lifts, wide door ways and corridors and accessible fittings such as light switches, and motorised doors. Whilst these modifications benefit people who use wheel chairs they can also benefit non-impaired people.
Economically society does not provide the same opportunities to people with impairments and places of work are often unnecessarily inaccessible to people with impairments.
Culturally, society lets people with impairments down because of the prejudiced views and negative shared attitudes of the non-impaired community towards people with physical and psychological challenges. Prejudice is associated with the recognition of difference, and “disabled” people are not seen as normal in the eyes of “non-disabled” people (Swain, Finkelstein, French & Oliver, 1993). Prejudices are evident in language and the terminology used to describe people with impairments, much of which is derived from medical labels. People are more than just a label describing a negative attribute, and the stigma attached to those labels means that people with impairments are held back from achieving what they want to achieve due to society disabling them.
History of the Social Model of Disability:
People with physical and psychological impairments have been represented in many ways by western society over the years – as holy, special, and unfortunately also in many less respectful ways. Several models have characterised the history of disability in the West:
The religious model, the medical/genetic model, bio-medical and more recently the social/human-rights model (Clapton & Fitzgerald, 1997).
These models or constructions of disability have had a powerful influence on setting the parameters for how people with impairments are treated by society. The most dominant of these models has been the bio-medical model. This model arose alongside and was fully supported by ground breaking advances in science and medicine. This gave the power and influence to the medical professions to dictate the lives of individuals with impairments.
According to the medical model the problem of disability is located within the individual, i.e. a person is disabled due to their individual impairments and therefore requires medical interventions to provide the person with the skills to adapt to society.
The model places individuals into medical categories for medical convenience. Doctors distribute categorical labels which carry social stigma, and these Doctors tend to be the adjudicators for resources to assist people with impairments. The medical professions own the knowledge and have the power to oppress people.
In the United Kingdom, the Disability Discrimination Act defines disability using the medical model (Wikipedia, 2001). However the medical model was far from perfect and before long it came under scrutiny by many disabled rights activist groups. The result of these protests was the introduction of a new model designed to overcome the oppression felt by many a person with disabilities. This model was the social model or human-rights model. Equalities Online states that the Social Model of Disability was initially introduced in the mid-seventies by a “disabled” lecturer Mike Oliver. He adapted it from a booklet published by the Union of Physically Impaired Against Segregation (UPAIS) titled Fundamental Principles of Disability. The social model opposed the oppression inflicted by the medical model, shifting the blame of disability from the individuals with impairments to an unfair, and oppressive society.
The social model has gained significant popularity, particularly amongst those people traditionally labelled as “disabled”. With the support of many human rights groups, some of the barriers of disability enforced by the medical model have started to come down. However there are still many mountains to climb.
2. ECRA – Enhanced Care Recovery Approach
Is born from a philosophy of care and a vision, it is an approach that supports and cares for people in their own homes. The approach encapsulates a comprehensive (holistic, integrated) approach and recognises the interdependence to achieve outcomes of indepence, rehabilitation and recovery, based on the “Social Model of Disability”. Smit, W. C. Enhanced Care Recovery Approach (2011) – Unpublished copyright.
3. MDT – Is an acronym used to refer to the Multi-disciplinary Team which may consist of support workers, nurses, Consultants, GP’s, physiotherapist’s health and social care workers speech and language therapist’s occupation health therapist’s dieticians and other health care professionals.
4. Hub for care – A private home/registered residential home within a community which is used to accommodate individuals as a transitional arrangement to establish the needs of that individual. This hub also offers the individual the opportunity to establish links with an appropriate support team and a key worker prior to transfer for long term tenancy placement within the community.
5. Pygmalion effect – The Pygmalion effect refers to the phenomenon in which the greater the expectation placed upon people, the better they perform. The effect is named after Pygmalion, a Cypriot sculptor in a narrative by Ovid in Greek mythology, who fell in love with a female statue he had carved out of ivory.
The Pygmalion effect is a form of self-fulfilling prophecy (This, and, in this respect, people with poor expectations internalize their negative label, and those with positive labels succeed accordingly. Within sociology, the effect is often cited with regards to education and social class however Focus Care Agency will apply it to our approach when supporting service users with disabilities and support workers delivering care and support.
6. Outcomes Based Tools – A document that has been developed and recognised as a valid outcomes measurement tool designed to map an individual’s journey towards reablement/enablement/independence and recovery. It uses a ‘Ladder of Change’ as a framework for service user’s, supported by their key-worker, to explore key themes in working towards individualised goals i.e. Self-care, Living skills, Social networks, Work, Relationships, Addictive behaviour, Responsibilities, Identity and Self-esteem, Trust and Hope, Care Planning, Communication, Information Sharing, Tranisitions and Decision making.
7. Valuing People Now – Is a three year cross government strategy for people with learning disabilities. It says that all people with a learning disability are people first with the right to lead their lives like any other.
8. Holistic Integrated care/support – This is a comprehensive approach to support and care i.e. physical and psycho-social with the service user sentral to all aspects of the pathway.
British Council of Disabled People. (1981) The Social Model of Disability. Derby. http://www.bcodp.org.uk/about/research.shtml
Clapton, J. & Fitzgerald, J. (1997) New Renaissance magazine: The History of Disability: A History of ‘Otherness’. Vol 7, No 1. http://www.ru.org/artother.html
Equalities Online. What is the Social Model? Birmingham.gov.uk http://www.birmingham.gov.uk/GenerateContent?CONTENT_ITEM_ID=1196&
Shaw Trust – Ability at work (2005) Disability and employment statistics. http://www.shaw-trust.org.uk/page/6/89/
Swain, J. Finklestien, V. French,S. & Oliver, M. (1993). Disabling Barriers – Enabling Environments. SAGE: London.
UPIAS (1976) Fundamental Principles of Disability. Union of the Physically Impaired Against Segregation.
Wikipedia-The Free Encyclapedia (2001) The Social Model of Disability. http://en.wikipedia.org/wiki/Social_model_of_disability
Department of Health UK (2009). Valuing People Now: Delivery Plan (2010-2011). London: Crown
Barton, L. (1996), Disability and Society: Emerging issues and insights, Longman, London.
Campbell, J. and Oliver, M. (1996), Disability Politics: Understanding our past, changing our future, Routledge, London.
Oliver, M. and Barnes, C. (1998) Disabled People and Social Policy: From Exclusion to Inclusion, Harlow, Longman
Oliver, M. (1996) Understanding Disability: From theory to practice, Macmillan, Basingstoke.
Oliver M (1989) Disability and Dependency: The Role of Education’in Struiksma, C and Meijer, F (eds) Integration at Work. Rotterdam, Pedagogical Institut, Rotterdam.
Shakespeare, T. (1993) Disabled people’s self-organisation: a new social movement?‘ Disability and Society, 8, 3, pp. 249- 264.
Shakespeare, T. (1995b) Redefining the disability problem, Critical Public Health vol 6 no 2, pp 4-8
Shakespeare, T. (1996c) Disability, identity and difference, in C. Barnes & G. Mercer (eds) Exploring the Divide: Illness and Disability, Leeds: The Disability Press
Shakespeare, T. & Watson, N. (2001a) Making the difference: disability, politics, recognition, in G.A. Albrecht, K.D.SEELMAN & M.BURY, The Handbook of Disability Studies, Thousand Oaks: Sage, pp 546-564
Shakespeare, T. & Watson, N. (2001b) The social model of disability: an outdated ideology?, Research in Social Science and Disability volume 2, pp 9-28