Maximising Recovery, Promoting Independence: An Intermediate Care Framework for Scotland

4. Why do we need Intermediate Care?

A well configured, integrated health and social care system which includes a range of Intermediate Care options can contribute significantly to the reshaping care agenda by:

• Preventing unnecessary acute hospital admission or premature admission to long-term care;
• Supporting timely discharge from hospital;
• Promoting faster recovery from illness, and
• Supporting anticipatory care planning and the self management of long-term conditions.

The need for change is clear - the demographic changes facing Scotland are well documented:

• over 65 population projected to increase by 22% by 2020, and by 63% by 2035;
• The over 75 population predicted to increase by 23% and 82% over the same period⁵;
• over 85 population will increase by 39% by 2020 and 147% by 2035.

We currently spend approximately £5.1 billion^a of public funding each year on health and social care for those over 65 years across Scotland. Well over half (60%) of this is spent on care in hospitals and care homes (and almost one-third on emergency admissions to hospital).⁶ Overall, emergency admissions by older people absorb £1.4 billion each year and are expected to grow unless we radically change our approach to addressing peoples needs in the community.

"Our policy goal is to optimise the independence and wellbeing of older people at home, or in a homely setting. This will involve a substantial shift in focus of care from institutional setting to care at home - because it is what people want and provides better value for money."

Reshaping Care for Older People:
A Programme for Change 2011-2021

This projected growth in the older population will create significant additional demand on health, care and support services. Assuming that demand increases in line with the growth in the older population and that current service models remain the same, we would require an annual increase in investment in health and social care services alone of £1.1 billion by 2016. There will be additional demands on other services.

Reshaping our services for older people can change this. We have already made some progress in this area, but we need to do more. Intermediate Care has a key role to play in meeting the health and social care needs of people in Scotland.

Preventing unnecessary acute hospital admission or premature admission to long-term care

An important concern for older people is the increasing likelihood of unplanned or emergency hospital admission as they develop more long term conditions and complex needs. The probability that someone will be admitted to hospital increases with age (Chart 1) as does the average time spent in hospital after admission (Chart 2).

Many admissions are absolutely necessary. Some however can be avoided - if we take the right anticipatory action and if we ensure that effective alternatives are available in the community. A key outcome of reshaping care will be reducing the number of bed days used as result of emergency admissions to hospital by older people.

A new NHS HEAT target introduced from April 2012 is to reduce 75+ emergency bed day rates by at least 12% nationally between 2009/10 and 2014/15.

To avoid unnecessary admission to hospital alternative community services need to be in place to effectively respond to those in crisis. Providing a range of integrated intermediate interventions within community services will ensure timely support is available to those who need it, where they need it. Intermediate Care is not just a health, or social care agenda. There is a role for all - health, social care, housing, the third and independent sectors - alongside families, carers, neighbours and the wider community.

Chart 1: Emergency admissions as a percentage of population in age band

Chart 2: Average length of stay per emergency admission by age

Supporting timely discharge from hospital

Unnecessary delays in discharge from hospital are not only costly to the NHS but are detrimental to the health and wellbeing of the individual. Unnecessary delays can lead to decreased independence and life skills, lack of confidence and a risk of further illness. All of this can lead to an increased risk of premature admission to a care home, instead of a return home.

The risk of becoming delayed in hospital increases when a patient is admitted as an emergency, and the longer the delay the greater the chance of dependency and a reduced chance of a return home. Therefore both the emergency admission and its outcome may be expensive - in financial and human terms. In contrast, greater support upstream might have helped to prevent an avoidable admission, at lower cost.

Our evidence demonstrates the need for public services to become outcome-focussed, integrated and collaborative. They must become transparent, community-driven and designed around users' needs. They should focus on prevention and early intervention.

Commission on the Future Delivery of Public Services

There has been much progress in tackling delayed discharges. In October 2001 there were more than 2,000 patients delayed longer than 6 weeks.

New Delayed Discharge Target

Partnerships will reduce to zero the number of delayed discharges:

• over 28 days by April 2013,

and

• over 14 days by April 2015

A target to reduce this to zero by April 2008 was achieved and the numbers delayed over 6 weeks generally remain below 100.

However, delayed discharges still account for nearly a quarter of a million bed days lost.

An expert group, jointly established between the Scottish Government, NHSScotland and COSLA, reported at the end of September 2011⁷.

The group recognised the achievement over the last few years but felt that, from an outcomes perspective, a six-week delay in hospital discharge is too long in nearly all cases. The group suggested that major cultural and behavioural change was needed to move to a position where discharges routinely take place in days and not weeks and that people are, wherever possible, discharged home or to where they were admitted from.

Promoting faster recovery from illness

It is clear that prolonged hospital stays are generally not good for a person's general wellbeing, especially their sense of control and independence.

To ensure that their potential for recovery is maximised, an individual should have the opportunity to recover at home or within a community setting supported, where required, by an appropriate package of Intermediate Care.

This recovery time could avoid premature admission to a care home - currently, too many older people are discharged directly from hospital to a care home at a time when their confidence is low following an acute illness.

The development of Intermediate Care, such as Rapid Response Teams; community assessment and rehab teams, or hospital at home schemes, can help avoid admission to the acute sector, promote faster recovery from illness, and reduce delays to discharge from hospital.

Supporting anticipatory care planning and self management of long-term conditions

"Introduce a systematic and integrated multi-agency approach across CHPs to provide better, local and faster access to services for people with long term conditions who require proactive and co-ordinated support."

Improving Health & Wellbeing Of People With Long Term Conditions In Scotland: A National Action Plan

Around 2 million⁸ people in Scotland have at least one long term condition, and one in four adults report some form of long term illness, health problem or disability. Long term conditions become more common with age. By the age of 75, nearly two-thirds of people will have developed a long term condition. 27% of people aged 75-84 have two or more such conditions.

The human costs of long term conditions and the economic consequences for health and social care are profound.

• Sixty per cent of all deaths are attributable to long term conditions and they account for 80% of all GP consultations⁹.
• People with long term conditions are twice as likely to be admitted to hospital, will stay in hospital disproportionately longer and account for over 60% of hospital bed days used.
• Most people who need long term residential care have complex needs from multiple long term conditions.¹⁰

"People with dementia want services which maximise capacity for independence and which connect or reconnect people with dementia with the people and activities important to them."

Scotland's National Dementia Strategy

Approximately 71,000 people in Scotland have dementia, around 2,300 of whom are under 65. Alzheimer Scotland estimates that the cost associated with Dementia are £1.7 billion per annum. Of that cost around £600 or £700 million is the cost of care and treatment services provided by the NHS and local government. The remainder is the contribution made by carers¹¹. There are 657,000¹² carers in Scotland saving the Health and Social Care system an estimated £10.3 billion.

Most people with dementia (over 60%) live at home, with carer support from family members (usually a partner or daughter), often supported by a range of community and health care services.¹³

• Older people with dementia will have significantly more functional decline, longer lengths of stay, increased risk of admission to a care home and higher mortality rates. It is well known that elderly people with significant physical disease are at greater risk of co-existent psychiatric morbidity¹⁴.
• People with dementia are many times more likely to be admitted to hospital compared with older people who do not have dementia.

Most people who live with a long term condition manage their own condition or do so with help from family, unpaid carers or from community and voluntary sector partners. Supported self management encourages people to take decisions and make positive choices about their health, wellbeing and health-related behaviors. It involves a holistic assessment of personal goals. A self management plan is a way of recording these personal goals and the supports people need to achieve them. It is designed to be held and used by the person at home.

A recent study aimed at reducing unplanned hospital admissions highlighted that the use of Anticipatory Care Plans for those at high risk of a hospital admission was found to reduce the number of admissions and occupied bed days¹⁵.

Anticipatory care planning encourages people to make positive choices about what they should do themselves, and from whom they should seek support, in the event of a flare up or deterioration in their condition, or in the event of a carer crisis. This approach supports important outcomes:

• Person centred care, dignity, choice and control
• Effective co-ordination and communication between the individual, their family and the health and social care professionals involved
• Planning for the future at a stage when the person can make their preferences known, enabling them to be actively involved in planning their own future.
• Care at home where appropriate, or care which is more local and closer to home.