Maximising Recovery, Promoting Independence: An Intermediate Care Framework for Scotland
A framework to help local health and social care partnerships design and improve intermediate care services in their locality
3. What is Intermediate Care?
"The function of intermediate care - inherent in its name - is to integrate, link and provide a transition (bridge) between locations (home/hospital and vice versa); between different sectors (acute/primary/social care/housing); and between different states (illness and recovery, or management of acquired or chronic disability)."
An Evaluation of Intermediate Care for Older People, Institute of Health Sciences and Public Health Research, University of Leeds, 2005
Rehabilitation, reablement and Intermediate Care (IC) are all terms that have currency in a variety of health and social care settings. However, they all stem from a desire to enable individuals to live independent lives with meaning and purpose, to empower individuals to be self determined, and to avoid dependency on health and social care.
Intermediate Care is an 'umbrella' term describing an approach involving a collection of services working to common, shared objectives and principles. It provides a set of 'bridges' at key points of transition in a person's life, in particular from hospital to home (and from home to hospital) and from illness or injury to recovery and independence; helping them achieve their personal outcomes.
By its nature in acting as a bridge between locations, sectors and personal circumstances, there must be close connections with mainstream services - whether the acute sector or community based services.
Intermediate Care should be brought in at times of "crisis" to complement existing care services (where these are in place), providing a person centred, outcomes focused package of care. It can also form part of a range of planned interventions, this is particularly important for those with long term conditions. Wherever possible this will be provided in the person's own home, but a range of services are likely to be needed, including care homes and community hospitals. Good practice would suggest that part of the suite of services provided in local areas should be available on a 24/7 basis, with a fast, easy, single point of access to assessment.
The diagram below illustrates how Intermediate Care can be delivered to ensure the best quality care is provided at a point of crisis to avoid an acute admission, or to assist in returning that person to the community.
Level of acute need |
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Individual becomes unwell. Primary care; District Nurse; Social Work; Home Care; NHS24; Ambulance practitioner; A&E attendance. Contact Single Point of Access Assessment Intervention as required:
Timely diagnosis by GP Specialist input by:
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If too unwell to be cared for at home, step up to a care home, community hospital or other residential setting. History / Examination / Diagnostics. GP, Nurse practitioner or Consultant review within 24 hours. MDT input with principle of care delivery at home when appropriate (as it may be in a care home). |
If too unwell to be cared for in a community facility, admit to acute hospital for comprehensive assessment. Transfer to community facility or home when medically stable and fit for transfer. |
Level of need during recovery |
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Timely comprehensive multidisciplinary and multi-agency assessment : Rehabilitative need identified. Referral to Intermediate Care Single Point of Access. Individual is medically stable and fit for transfer. Individual transferred to the appropriate setting:
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If the individual requires more care than can be delivered at home, step down from acute hospital to a care home, community hospital or other residential setting. Regular MDT and GP / Nurse / Consultant review with principle of care at home to continue rehabilitation when appropriate |
Majority of users of Intermediate Care to receive their episode of care at home. MDT driven re-ablement to optimise recovery and promote independence. |
Contact
Email: Isla bisset
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