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

5. Key components of an effective Intermediate Care system

The following are key components of Intermediate Care:

• Clear, agreed scope, focused on prevention, rehabilitation, reablement and recovery; for those at risk of emergency admission, or re-admission, to hospital, or to avoid premature permanent admission to a care home.
• Time limited, linking and complementing existing services
• Accessible, flexible and responsive through a single point of access, 7 days a week, and 24 hours a day
• Based on holistic assessment to maximise independence, confidence and personal outcomes sought by the individual
• Co-ordinated, able to draw on multi-professional and multi-agency skills and resources as required to meet complex needs
• Managed for improvement, gathering information on the impact of interventions and using this to inform service improvement.

Clear, agreed scope, focused on prevention, rehabilitation, reablement and recovery

Partnerships should set out clearly the scope of the local IC system. This should make it clear the profile of needs and circumstances which IC can assist. This should be developed in collaboration with all stakeholders and reflect the overall purpose of Intermediate Care and the particular needs in the area.

Partnerships also need to understand the range of different needs within their local population. Understanding the needs of the local population will assist commissioners to develop appropriate services, with the right skill mix to meet the range of needs identified.

Intermediate Care is concerned with prevention, rehabilitation, reablement and recovery- building on support for self management and anticipatory care by helping to avoid the need for emergency admission to acute hospital (prevention and early intervention); promoting faster recovery and more timely discharge (rehabilitation & recovery); and helping people to re-learn vital life skills (reablement). Intermediate Care brings benefits both to the people using it and to the health and social care system. Its focus should therefore be on those at risk (of emergency hospital admission or delayed discharge); and those with potentialto regain confidence and independence.

The use of Anticipatory Care Plans (ACPs) supports those with long term conditions to make informed decisions and plan for an expected change in health or social status.

"An Anticipatory Care Plan is a dynamic record that should be developed over time through an evolving conversation, collaborative interactions and shared decision making. It is a summary of discussions between the person, those close to them and the practitioner." ¹⁶

Where an individual does not have an ACP thought should be given to developing one prior to the completion of their episode of Intermediate Care. Where appropriate, time should also be taken to discuss with the patient and carer how they can look after their health and wellbeing at home. The nature of self management support will vary depending on the individual, but could include general advice on healthy eating and exercise, specific information and advice on, for example, changing a dressing, managing their medicines or foot care, or signposting to local community support.

Key Information Summary

ACPs and other forms of e-records also need to be shared with the full range of care providers, including SAS so that all services can respond appropriately to the needs and wishes of the individual. The Key Information Summary (KIS)¹⁷ has been developed as an electronic method of sharing patient information with all clinicians, including SAS.

Developing on the Emergency Care Summary and electronic Palliative Care Summary, the KIS has been designed to support people with long term conditions, mental health problems and individuals requiring special alerts.

In Chapter 7 we set out some scenarios which relate to the wide range of different needs and circumstances of those who could benefit from Intermediate Care.

We encourage local partnerships to think in particular about the needs of:

• A frail older person who falls at home or in a care home.
• A homeless person with complex medical and social problems.
• A person with a long term condition whose condition deteriorates.
• An older person with dementia, who develops an acute health problem.
• A person recovering from a stroke, whose housing no longer suits their needs.
• Additional pressure on carers following a hospital episode (of the cared for person).

In practice, IC has particular relevance to older people, particularly those aged over 75 and 85, who are at greatest risk of admission to hospital and where there is a related risk of a delay in discharge or admission into a care home. This is often at a key point of transition in their lives, as they acquire a chronic illness or disability, or experience some sort of acute illness, such as a fall or infection.

However, as there is no common understanding about the purpose, scope and needs profile for IC, not all who would benefit are referred on. Partnerships should set out clearly those who would benefit from Intermediate Care and ensure that this is widely understood, and that all individuals have the opportunity to benefit from Intermediate Care.

The full scope of the local Intermediate Care system is potentially very wide. While it should clearly be the medium term aim to enable it to assist all of those who would benefit, in practical terms it is sensible to start with a more limited scope and expand it over time as systems, processes and staff skills and experience develop.

This more limited scope could be around particular profiles of need, or circumstances; or it could be that it makes sense to start in a particular location. Whichever approach suits the local area, it is important (a) to set the programme for scaling up, and (b) to ensure that this is understood and shared amongst staff and partners.

Time limited, complementing existing services

The purpose of Intermediate Care is to provide time-limited interventions at points in a person's life where this will restore or avoid a loss of independence and confidence, or reduce the risk of hospital admission (or a longer stay in hospital).

Experience suggests that Intermediate Care should extend for up to 6-8 weeks. After this period of time, the pace of recovery tends to slow and the person no longer receives the same level of benefit from the intensive interventions associated with Intermediate Care. However the period of time during which Intermediate Care should be provided should reflect the needs of the individual and be shorter, or longer, as appropriate. Intermediate Care is one form of rehabilitation targeted at those who will benefit from short term, intensive, and multi professional interventions: other rehabilitation services may well continue (as may the period of recovery) well beyond this 6-8 week period.

Intermediate Care should be provided, free of charge, to people in their own homes where possible: this reflects the clear priorities of older people. Free and effective Intermediate Care has the potential to pay its own way, when commissioned as part of a wider suite of integrated resources.

Intermediate Care in these circumstances is additional, and should be complementary, to any existing services that the person receives. It should not displace existing care and support arrangements, but seek to enhance and keep these in place.

This continuity is of particular importance for older people who are confused, and where maintaining routine is a key component of retaining their independence.

In other circumstances, this will not be possible and a move to another setting, such as a care home or community hospital, may be required.

Whether Intermediate Care is provided in a person's home, or in another setting, good communication and a smooth 'handover' with mainstream services is essential. Good links and information sharing needs to be established with the wider infrastructure of community health and social care services, in particular:

• Homecare services;
• The care home sector;
• Day care;
• District Nursing & GPs;
• Pharmacists
• Voluntary organisations; independent providers and social enterprises
• Community mental health teams
• Geriatric assessment services

Clear information for the individual, their family and carers is also essential including:

• Signposting to appropriate future services, either from statutory organisations or the third or independent sector.
• Advice and training on self care and management of long term conditions
• Follow up support should be identified, other agencies contacted and involved in the ongoing care needs.

Accessible, flexible and responsive

Access to Intermediate Care should be speedy and as direct as possible, avoiding multiple referrals or complex pathways. This is particularly important where the focus is preventative and where any delay could prejudice the ability to achieve the desired outcome.

For the same reasons, access needs to be 7 days a week, and 24 hours a day. The ability to reduce the need for emergency admission to hospital would be seriously compromised without this 24/7 access. This does not mean that all Intermediate Care services have to be available: simply that a person can be referred and their immediate needs met 24/7.

People will 'enter' Intermediate Care from a multitude of different points in the local health and social care system. The main sources of referrals are likely to be from:

• Entry and exit points to acute hospital, including A&E, Admissions Wards, and those planning discharge
• Mainstream community based services, such as home care, district nurses or GP practices
• Emergency services, such as the out of hour's service and the Scottish Ambulance Service.

These are likely to be the most immediate referral points: however routes may be more varied and complex. For example, there may be referrals from the homeless team or Mental Health services. Key to making the system accessible is to minimise the number of contacts which a person needs to make before accessing Intermediate Care.

There is no 'right' design: rather it needs to reflect and incorporate the local health and social care system.

Most of the routes into Intermediate Care are reactive responding to contact being made as the result of a change in needs or circumstances. However there are approaches which are more proactive in nature such as discharge planning to identify people who might be suitable for Intermediate Care; and systematic review of emergency respite placements and anticipatory care planning.

The particular issue about avoiding unnecessary admission to hospital has led a number of areas to develop 'admission avoidance services' located physically at the point of entry into an acute ward: within A&E and the Medical Assessment Unit.

The emphasis of these teams is to develop an overall picture of the person in a wider social and health context and not just focussing on the immediate reason for presenting to hospital.

Because of the wide range of different needs and the multiple pathways that people will follow, there are significant benefits in establishing a single access point for all those who may benefit from Intermediate Care. This provides a clear 'route in' to Intermediate Care, which can be widely publicised within the local health and social care system, and to the general public. It also enables there to be consistency in the assessment process and service delivery.

Holistic assessment around personal outcomes

At point of access to the local Intermediate Care system, the individual's needs and priority level should be identified quickly and passed to an appropriate responder. Algorithms can be developed and effectively used to do this. This must be supported by assessment processes which are fair and consistently applied across the partnership area.

The Self-directed Support (Scotland) Bill will place a duty on councils to offer choice to all people eligible for support under the Social Work (Scotland) Act 1968. It is expected that this stage will be at the conclusion of a period of Intermediate Care (IC). In circumstances where the provision of IC is provided under the 1968 Act then these duties will apply from the outset.

Any assessment for IC should sit within the local partnership's approach to outcomes and sit within the partnership's wider approach to personalisation, offering:

• Personalisation as prevention - services that are designed to build the capacity of individuals and communities to manage their own lives with appropriate and proportionate intervention at the right time.
• Personalisation for people with complex support needs - help people to find the right support solutions for them and to be active participants in the development and delivery of services.
• Personalisation as choice - sometimes people just want to have efficient, reliable "off the shelf" services which respond to their needs when they have them.

Assessments should be holistic and related to the individual's needs and the personal outcomes they seek. A number of example assessment tools, developed by local partnerships, are available on the Joint Improvement Team's website at http://www.jitscotland.org.uk/action-areas/talking-points-user-and-carer-involvement/sample-tools/.

Key amongst these is Talking Points, centred on three frameworks of outcomes, one for people using community services, one for unpaid carers, and one for care home residents. The care homes framework was recently developed, following a pilot exercise in three care homes in the Scottish Borders. A report of the pilot is available on the JIT website at http://www.jitscotland.org.uk/action-areas/talking-points-user-and-carer-involvement/.

A key issue in assessment for Intermediate Care is whether or not the person is medically ready for Intermediate Care - the issue of 'medical stability'. There are particular challenges in relation to older people with cognitive problems, where it is particularly important that skills are re-established within the familiar home environment but who may present with a complex set of medical problems. There are also challenges in relation to people with other mental health problems, such as depression. Acute care at home offers particular advantages for people in these circumstances.

Coordinated, multi-professional and multi-agency

Intermediate Care needs to be able to draw on expertise from a wide range of services including health, social care, housing and from the public, independent and third sectors. An effective local Intermediate Care system requires effective co-ordination of this wide range of service inputs; it also requires a capable workforce.

Coordination

There are two levels at which coordination of Intermediate Care is needed

(a) System level coordination (strategic)

(b) Coordination of the individual's Intermediate Care package (operational)

The effectiveness and quality of the local Intermediate Care system will be undermined if there is insufficient system level coordination - arrangements must enable multi agency and multi professional inputs to be secured at the point at which the individual needs them. Most local Partnerships will decide to have some dedicated intermediate care services, particularly to provide the core coordination and assessment functions; but it will still be necessary to pull in wider service contributions to create integrated and holistic packages for people, especially those with complex needs.

Effective system level coordination requires:

• Promotion of the services and provision of information to both staff, and users and carers
• Pathways, protocols and eligibility criteria for access to services (including the Scottish Ambulance Service)
• Agreement between agencies and organisations which will contribute to Intermediate Care - the statutory, independent and third sectors; primary care, community care health services, social care, housing and the acute sector.
• Effective leadership and champions to challenge historical ways of working and resource allocation.
• Funding of Intermediate Care, and arrangements for use and distribution of this funding
• A process for resolving any disputes or difficulties.

While agreement on these issues should be set out in writing between the partners, so that there is a shared and widespread understanding of role and responsibilities, it is important not to hinder the development of Intermediate Care by a lengthy negotiating process. .

The multiplicity of different pathways, circumstances and needs amongst those who will use Intermediate Care has led many local partnerships to appoint an Intermediate Care Coordinator¹⁸.

Partnerships who have not already done so should consider jointly appointing a dedicated Intermediate Care co-ordinator (or co-ordination team). The role of the Intermediate Care co-ordinator will vary, depending on what services are already in place locally, the degree to which they are integrated, and the numbers, skills and experience of staff. The co-ordination function must operate at both strategic and operational levels. Some areas with complex organisational structures may need more than one person to ensure that all tasks are performed.

Individual case coordinationis also required so that people experience an integrated package of interventions. Dedicated intermediate care services are likely to provide certain core services within the local system: however the range of complex needs, and the varying personal outcomes that people will seek, inevitably means tailored packages of care.

It is essential that one person co-ordinates the response to all care needs and develops a multi-disciplinary treatment plan which can draw other services. This treatment plan should be communicated, implemented, monitored and reviewed.

Multi-professional, multi-agency skills

The need for integrated services brings with it a requirement for staff to be flexible and responsive. This is recognised as a key component of the Reshaping Care programme and reflects earlier policy documents and workforce development supported by NHS Education for Scotland and JIT. Capable, Integrated & Fit for the Future: A Multi-Agency Capability Framework for Intermediate Care¹⁹ sought to encourage a

"...capable workforce that has the skills to support better health, better care for older people and people living with long term conditions. It helps build an integrated workforce that is fit for the future and helps people realise their full potential for health, independence and wellbeing."

In planning tomorrow's workforce today we need to take a more integrated approach to developing the capability of staff.. This includes extended roles for staff and more collaboration in creating development opportunities across care settings and sectors. Developing the workforce in acute, primary and community care settings is vital to delivering a shift towards community based services which are modern, safe and sustainable and give better and faster access to care locally.

In today's climate tasks are being delegated to more appropriately trained staff, freeing up the time of higher qualified staff to undertake more specialised work²⁰. The appropriate use of skilled support workers can improve the continuity and experience of care, bridging the gap between health and social care by combining social care with rehabilitation skills²¹. However to successfully achieve this task delegated, support workers require appropriate training in rehabilitation and re-ablement and confidence to know when they have reached the limits of their capability²².

Partnership Example of Good Practice

STARS (Short-Term Augmented Response Service) staff training

NHS Dumfries & Galloway

STARS provides a 6 month, intensive reablement training course "Promoting self management, enablement and rehabilitation at home" for support workers. The course content is delivered by health and social care practitioners/professionals dedicated to improving support worker role development and delivering quality reabling services to service users.

The overall aim of this training and development programme is to enable Health and Social Care Support Workers (HSCSW) to develop and evidence effective knowledge and practice skills which can be used particularly within the home environment to promote service user self management, enablement and rehabilitation, under the direction of registered appropriate professionals. Learning is levelled at Scottish Credit and Qualification Framework (SCQF) Level 6 in line with the NHS Career Framework and Social Services role requirements to promote quality assurance and support regulation agenda. The training package is in the process of being accredited formally at SCQF6 to meet the needs of health and social care support workers and at the final phase of the validation process within the Scottish Qualification Authority (SQA) in partnership with Scotland's Colleges led by Dumfries College to become a nationally recognised National Progression Award (NPA).

To date 75 support workers have enrolled, ranging from nursing auxiliaries, physiotherapy assistants, occupational therapy assistants, generic health care support workers, social care support workers and mental health assistants. Students gain training from nursing and allied health care professionals from health and social care backgrounds as well as hearing from a service user guest speaker about the experience of managing a long term condition. Interactive learning includes presentations, practical skills lab and e-learning opportunities. Support worker are asked to evaluate their scope of skills, knowledge and confidence upon enrolment and then upon completion of the training have all reported improvements ranging from initial 'limited' or 'basic' to 'developing' or 'competent'. Support workers comments upon completing the course have included:

Participants Feedback:

• "I thoroughly enjoyed course definitely improved my confidence and ability to do my job better and maximise opportunities to support service users to live as independently as possible"
• "Folder is a good learning tool to recap on conditions, effect on every day life and strategies to help"
• "Understanding different professional roles and the practical classes helped consolidate my learning - thank you to all who took time out to support our learning and development"

Further information is available from Gail Edgar, STARS Service Manager or Wendy Thomson, OT Development Facilitator and Programme Lead, STARS on 01387 241500.

Managed for improvement

Managing for improvement involves understanding the contribution that Intermediate Care makes at 3 interlinked levels

(a) For the individual using the services

(b) For the local Intermediate Care system

(c) At whole system level.

Impact at the level of the individual needs to be able to capture personal outcomes and the 'distance travelled' by the individual during the period that they received Intermediate Care: what improvements in quality of life has Intermediate Care enabled the individual to achieve? This requires gathering information on the individual's position at 'entry' to Intermediate Care, and comparing this to the position at 'exit'. The use of outcomes based evaluation tools, such as Talking Points, provide a useful framework for this process. Data on distance travelled needs to be related to service inputs to inform service improvement.

Care needs to be taken in the interpretation of the data captured at individual level. 'Success' cannot simply be considered as the greatest distance travelled for the least service input - this will hide the huge variety of needs and capabilities amongst those using Intermediate Care. Success for one person may be the ability to be able to stand unaided again - while for another with similar abilities at the outset, it may be the ability to be able to walk upstairs.

A challenge for the Intermediate Care system is that its performance will depend in large part on the effectiveness of contributions made by other services. The development of standards, and the associated indicators, to assess these contributions will be key to gathering information for service improvement.

For example, good practice standards and indicators may be to:

• Develop written service objectives which are widely communicated to all stakeholders.
  • Are there clear service objectives?
  • How are these communicated?
• Develop service standards for Intermediate Care, and for the assessment and provision of the services.
  • Are there service standards in place?
  • How/when are these monitored?
• Agree a concise range of performance indicators with key stakeholders and use to monitor effectiveness in all areas of Intermediate Care. These should include response/delivery times, business efficiencies, service demand, complaints, training and the outcomes for the individual.

• Has the service identified performance indicators?
• Are these effective in evidencing service improvement?
• How will the information gathered from service users inform this wider service level assessment?

Intermediate Care should also be considered as part of the wider whole system levelmeasurement, particularly in relation to the prevention, efficiency and well-being agenda. It should be expected to contribute to wider system level improvements in delayed discharge and emergency admission bed day rates.

In line with the recommendations from the Delayed Discharge Expert Group report a new target has been introduced to further reduce the number of delayed hospital discharges:

• 28 day maximum wait for discharge to be achieved by April 2013;
• 14 day maximum wait by April 2015.

Health and social care partnerships are also now required to monitor the number of bed days lost through delayed discharge. Local trajectories could be set by local partnerships to reduce the number of bed days lost. Making effective use of Intermediate Care services, will over time reduce the level of patients delayed, and the length of these delays.

Partnership Example of Good Practice

Highland inter-agency working

The multi-disciplinary/agency team, including primary & secondary care, social work and home care, work together to support the acute & community hospitals by providing quick access to step down beds in a local care home. The MDT also provides a hospital at home service, with consultant input and can spot purchase home care to speed up access to the service, and facilitate timely discharge from hospital.

This multi-agency approach has seen improvements through the reduction in bed days lost (saved 354 bed days over a 12 month period) and increased throughput.

Commissioning

The Reshaping Care for Older People Programme asserts that good Joint Commissioning Strategies are essential if partnerships are to achieve a significant shift in the balance of care away from institutional settings towards community settings.

Strategic commissioning is the term used for all the activities involved in assessing and forecasting needs, links investment to agreed desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place.

Joint commissioning is where these actions are undertaken by two or more agencies working together, typically health and local government, and often from a pooled or aligned budget.".

With an ageing population and diminishing resources Councils and NHS Boards will need to ensure that joint decisions are taken around the management of mutually committed resources such that investment and disinvestment in health and community care services are effectively planned and coordinated.

The Scottish Government signalled to local authority/NHS Partnerships in the 2011/12 Change Fund guidance that future years plans should take the form of Joint Commissioning Strategies. These Strategies and associated governance arrangements provide an opportunity for the Third and Independent sectors and carers to become fully embedded in and strengthen the planning arrangements established during the first year of the Change Plans.

We have established a National Steering Group on Joint Strategic Commissioning. This group will set the direction for strategic commissioning in health and social care nationally in order to assist local partnerships with the formulation of local commissioning plans. In addition, we are developing a National Learning Framework to provide a longer term structured approach to support and learning. This Framework seeks to underpin a national approach to strategic commissioning by identifying the learning needs of partnerships, and by building capacity to deliver cogent and consistent outcome based commissioning in Scotland. The purpose of the Framework is:

• to provide a comprehensive, consolidated picture of current activity to support practice improvement and learning across all aspects of joint strategic commissioning.
• to identify gaps in current activity and arrangements.
• to develop a framework for action to address the identified gaps and weaknesses.
• to promote positive, creative interplay between stakeholders and sectors in order to maximise the impact of the specified learning.

The JIT have developed a number of useful guides to help partnerships through commissioning processes, and are available on the internet at: http://www.jitscotland.org.uk/action-areas/commissioning/.