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

6. Specific Services and Functions

As noted previously, Intermediate Care is an umbrella term that refers to a set of functions and services which share a common purpose - creating a bridge between the person's home and hospital / care home settings.

This section aims to provide more detail and further examples of Intermediate Care including the work of the Intermediate Care Demonstrator sites.

Triage, Early Diagnosis and Assessment

Important principles of an Intermediate Care system are prompt, safe and effective streaming to the appropriate acute care /service within the wider Intermediate Care system.

Access to Comprehensive Geriatric Assessment (CGA) for frail older people who will have greatest benefit is highly desirable. Randomised controlled trials of CGA show that organised care in Medicine for the Elderly wards increases the proportion of older people who return home from hospital, reduces length of stay, death and permanent care home outcomes. The effective triage at the onset of an acute episode plays a significant part in determining the subsequent journey of care and the outcome²³.

Compelling evidence for specialist led co-ordinated assessment and rehabilitation in acute care may have contributed to a reluctance for specialist older people teams to embrace community based alternatives. However, the reality is that many frail older people admitted to acute hospitals still do not access CGA, but are cared for in general medical wards.

Effective multidisciplinary care in the right setting through Consultant Geriatrician led community services, is a key component of the Intermediate Care system. The Torfaen Advanced Clinical Assessment Team provides a clear illustration of the benefits of rapid specialist assessment and diagnosis in the community. This team manages the person's care at home for between 24 hours to 14 days depending on the complexity of the care needs²⁴.

Partnership Example of Good Practice

East & Midlothian assessment beds

East Lothian has a number of 24/48 hour assessment beds, used to help prevent admission to hospital from home.

Similarly, Mid Lothian has developed a number of Intermediate Care beds which 'pull' patients from hospital (when suitable), giving them additional time to recover and receive appropriate rehabilitation, before returning home.

Acute Care at Home

Many terms have been used for this type of service, most commonly a Virtual Ward or Hospital at Home. Effective triage and assessment will determine whether a person is able to remain at home or will require acute care in hospital. Continued assessment and diagnosis is a key component of any acute care in the person's home and to be most effective must be well integrated with primary and secondary care and the wider Intermediate Care Team. A key feature of this component of Intermediate Care is the ability to deliver technical interventions e.g. intravenous antibiotics in the person's own home.

Other features are specific to particular medical conditions e.g. pulse oximetry or Chronic Obstructive Pulmonary Disease (COPD). General features are the co-location of key members of the team and full integration with the wider system. More recently services have shown the benefits of this approach also with dementia. In this example, teams provide rapid multi-disciplinary assessment and treatment in the person's own home working alongside the carer to resolve crisis without hospital admission. The average time of care given at home was 6.6 days but provision was made for interventions up to 6 weeks. This is an important development given that dementia is often associated with delayed discharge.

Intermediate Care Demonstrator Project

Perth & Kinross Transitional Care at Home Team (TCAHT)

The project

Assessment carried out within acute service admission wards (Ward 4, 7 & 8) to identify patients presenting with cognitive impairment / dementia and / or delirium and who may benefit from an early supported discharge service supported by the TCAHT comprising of a Transitional Care Nurse and three Social Care Officers with a special interest in dementia care.

This team had access to other professionals who provided support, advice, and assessment e.g. pharmacy, occupational therapy, physiotherapy, community nursing, Community Psychiatric Nurses (CPN) and psychiatric consultant. The Transitional Care Nurse was available Monday to Friday 8.30 am to 4.30 pm and the Social Care Officers provided a service 7 days a week from 8 am to 10 pm. Links were made with out of hour services such as community alarm, evening and overnight community nursing, social work services, mental health services etc.

Fourteen patients were accepted on to the TCAHT during the time period June 2009 to January 2010 from acute sector wards. The minimum length of stay was 4 days and maximum 23 days. The average length of stay was 11 days with a median length of stay of 10 days. There were no delayed discharges.

A full report from the Perth & Kinross Demonstrator Project is available to download at http://www.jitscotland.org.uk/action-areas/intermediate-care/

Multi-Disciplinary Rapid Response Community Teams

These teams are more commonly associated with the term Intermediate Care and can often also be called Rapid Response Teams, Community Rehabilitation Teams and Integrated Response Teams. The key principles of these teams is to provide a "wrap around" service for patients including a key worker, community rehabilitation assistants and access to a range of professionals across Health and Social Care.

These teams and services will tend to form the largest part of any Intermediate Care system, with the Allied Health Professions having a central role in design and delivery of care.

The main restrictions reported relate to out of hours services and 7 day working, as well as the need to have clarity regarding any overlap and links with other community services e.g. community nursing.

Partnership Example of Good Practice

Dumfries & Galloway STARS

Stars is a joint NHS/local authority project which provides a single augmented response service across Dumfries & Galloway. Previously, several augmented/rapid response services existed, all providing a very similar service but with different budgets and different management structures. In addition, these services were not able to cover the whole of Dumfries & Galloway and there were significant gaps in provision.

The Short-Term Augmented Response Service (STARS) was developed as a joint initiative between the NHS and Council in 2005. The services aims to:

• Facilitate safe discharge from hospital at the earliest possible stage;
• Avoid unnecessary admission to hospital; and
• Prevent premature dependence on long-term care.

Enhanced Supported Discharge

There is now extensive experiential and trial evidence to support community based models for post acute care and rehabilitation, including early supported discharge. This is most powerful in relation to stroke and hip fracture. Involvement of the Voluntary Sector can also be a feature of this service area.

The Intermediate Care Demonstrators in Orkney, Perth and Kinross and Fife all reported the positive impact of the multi-disciplinary teams on length of stay in hospital, prevention of admission, functional outcomes and experience of service users.

The main limitations reported relate to out of hours services and 7 day working, as well as the need to have clarity regarding any overlap and links with other community services e.g. community nursing.

Partnership Example of Good Practice

Enhanced Supported Discharge, Edinburgh Royal Infirmary

As part of the development of transformation plans under the Change Fund an Enhanced Supported Discharge team was established within Edinburgh Royal Infirmary. The team provided rehabilitation and re-ablement through AHPs, healthcare assistant and social care assistants to support discharge from acute medicine for the elderly, general medicine, stroke and respiratory wards in ERI.

The servicer was set up as a 7 day services, delivering care for up to 7 days per person, with a flexible approach on an individual basis. During the pilot 24 patients were supported resulting in:

• 109 bed days saved
• Reduction in average length of stay from 9.4 to 5.2 days
• Length of service provided in transition from hospital to community ranged from:
  • 1-5 days 57%
  • 6-10 days 33%
  • 11-14 days 10%

Example of Good Practice

Age UK Warwickshire 'Gateway'

In 2009 Care & Repair England began work on its 'if only I had known ..' programme to improve housing related help in hospital settings. Three areas were selected to pilot this work, one of which was Warwickshire Age UK and Coventry Care & Repair.

Hospital advice and information provided through leaflets and advice workers has developed into the Age UK Warwickshire 'Gateway' service, a call centre for assessment and referral. The aim is to support older people and vulnerable patients who would benefit from practical and social support. The provision includes housing related advice, information and practical help.

The scheme is particularly focused on discharge and helping minimise the risk for readmission. Needs are identified through Age UK Warwickshire advice and information staff in hospitals, and/or Gateway staff through phone calls and follow up home visits (where judged necessary). Individuals are referred on to an appropriate service provided by Age UK Warwickshire or other local groups, including Care & Repair agencies.

Key impact to date:

• Patients, hospital staff and carers have better, timelier access to information and advice about practical and social support, including for housing
• More needs are being met, and met quickly. The number of referrals from hospitals is increasing. Patients who agree to be contacted after they return home have been contacted within one working day of discharge
• More housing related issues are being dealt with:
  • A high percentage of all referrals include a housing/handyperson element.
  • Rugby Care & Repair developed a closer relationship with the discharge co-ordinator, nurses and OTs at Rugby St Cross hospital during the initial project. The has meant an increase in hospital referrals.
• Two of the eight hospitals that cover the county are working with Age UK Warwickshire to expand available support.

Further information on this and other schemes are available in the report If only I had known… Integration of housing help into a hospital setting and accompanying evaluation. Both these reports are available on the internet at http://www.careandrepair-england.org.uk/reports.htm.

Community Hospitals and Care Homes

Following admission to Acute care, frail older people frequently have a long length of stay within the acute sector. Where discharge home is not possible, then Community Hospitals can play an active role in the ongoing rehabilitation and recovery particularly of frail older people.

Although Intermediate Care is primarily a home based service model, for some people it is not possible to deliver Intermediate Care in the home environment. In this case a Community Hospital or Care Home, can provide a homely, holistic and effective environment for recovery closer to home.

Partnership Example of Good Practice

Intermediate Care Beds; North Lanarkshire

North Lanarkshire Council and NHS Lanarkshire piloted Intermediate Care beds within two care homes - Belhaven and Leslie House. The pilot has led to two adapted care homes being developed at Muirpark and Monklands House care homes (centres). The two care centres provide a total of 21 beds - 7 Intermediate Care; 6 Respite, and 8 for emergency situations.

The initial pilot was successful in preventing hospital admissions and in reabling people as part of a safe return from hospital, most often from A&E and emergency receiving beds.

Partnership Example of Good Practice

Links Unit, City Hospital Aberdeen

The Links Unit is a nurse-led Intermediate Care Service provided within a hospital setting. Patients can be admitted directly from A&E, or other hospital ward or by a GP in the community.

• The service aims to maximise the individuals potential for recovery, and ensure, wherever possible the person returns home.
• An estimated date of discharge is agreed by the multi-disciplinary team, including the patients doctor, and AHPs.
• Nurse makes decisions on who is admitted, ensuring most effective use of available beds.

Partnership Example of Good Practice

Angus Independent Intermediate Care Scheme (IICS)

Carnie Lodge, Arbroath

The Angus IICS is a stepping stone between hospital and home designed to help people move out of hospital quicker or to avoid an admission to hospital. People are assessed either at home or in a hospital and if appropriate, they are offered a place within a care home, with stay varying in length depending on need.

A range of support and rehabilitation services are available including physiotherapy, occupational therapy and 24 hour nursing care. Weekly review meetings are then held with all staff involved in the persons care to monitor progress and need, and make plans for them to return home - this is done in partnership with the person, their family and carers.

Since the service began in 2003/04 228 people were assessed and accessed the service from home, and 279 from a hospital setting.

NHS Pharmaceutical Care in the Community

NHS pharmaceutical care should have a prominent place in the provision of intermediate care, with pharmacists having an integral role in pathways of care and the processes underpinning it. This will be increasingly important as new models of care are developed as part of the wider vision and national outcomes for adult health and social care integration.

As we continue to see changes in the way in which care is provided, and shifts in the balance of care from hospital and other institutional care settings, it is recognised that there are significant opportunities for NHS pharmaceutical care to support people to live independently at home (or in a homely setting) through better supported self care and medicines management.

Local initiatives, such as the development of the 'virtual ward' and 'intermediate care demonstrator' projects in Fife, which are of continuing policy interest to the Scottish Government, will help to inform national approaches to the role of pharmacists and the pharmaceutical care they provide as key partners in the provision of intermediate care and care at home.

The outputs from these and other initiatives will be considered in conjunction with the conclusions and recommendations of the Review of NHS Pharmaceutical Care of Patients in the Community which is to report in October 2012.

Falls Prevention Services

Older people admitted to hospital after falling are more likely to be discharged to a Care Home than a comparative group of people admitted for any other reasons (Gilbert et al 2010). There is evidence that having a clear falls prevention strategy and a dedicated service in place as part of the Care Pathway reduces emergency hospital admission (Rose et al 2002).

The Cochrane review of interventions preventing falls in older people in the community (Gillespie and Handoll 2009) showed that these could reduce overall care costs by preventing hospital admissions. Successful interventions included group and personalised home based exercise programmes for strength and balance training.

Partnership Example of Good Practice

Edinburgh Falls Emergency Pathway

A partnership between the Scottish Ambulance Service (SAS), Edinburgh CHP (Intermediate Care, Community Alarm and Telecare Service (CATS), Social Care Direct, Primary Care) and NHS 24.

The SAS is now able to make referrals for the following falls services:

1. Alternative to conveyance to hospital

The SAS crew can complete an agreed falls protocol that will guide a decision towards whether a person requires to be conveyed to hospital or whether accessing a team that can carry out an urgent assessment at home is a more appropriate option. The crew can contact a call handler (in hours and out-of-hours) directly from the house to discuss the person's needs and options for assessment. The Rapid Response teams (Intermediate Care) in Edinburgh provide assessment and rehabilitation on same or next day to prevent unnecessary admission to hospital. An Occupational Therapist and Physiotherapist carry out an urgent assessment in the patient's home and arrange support and intervention as required for up to 5 weeks. The person can also be supported with a telecare package, including a response service.

2. Multifactoral Falls and Fracture Risk Assessment

The SAS crews can use the same falls protocol to refer for falls assessment and intervention targeted at modifiable risk factors, provided by intermediate care teams within 7-10 days, for those who have had a fall and are at high risk of further falls.

3. Fallen Uninjured Person Pathway

If a 999 call is received by SAS the paramedic advisors can direct the referral to the Mobile Response Service (CATS) who will go out to assist the person and refer on for falls assessment and telecare package as required.

Home Care Re-ablement

Initial research suggests that a home care service with a re-ablement philosophy is an effective and efficient alternative to the traditional model and is associated with improvements in health of the people using the services, with a high level of user satisfaction, staff involvement and commitment.

Re-ablement within Home Care services was first introduced by the City of Edinburgh Council in one area of the city in October 2008 and subsequently rolled out into other areas.

The Scottish Government commissioned an independent evaluation of the service during its first 8 months of operation - October 2008 to June 2009²⁵. The main findings were positive staff and service user satisfaction, reduction by 41% in the number of home care hours a person required after the re-ablement period, and 2/3 of those whose hours reduced required no further service at the end of the re-ablement period. These findings are similar to English and Australian studies²⁶.

Partnership Example of Good Practice

Cumbernauld Re-Ablement Service

The aims of the Reablement programmes are to assess service users' functional ability within their homes, to maximise service users' independence with activities of daily living and if an on-going home care service is required at the end of Reablement to recommend an appropriate service based on evidenced need.

The Cumbernauld Reablement Team consists of:

1 FTE Occupational Therapist.	2 FTE Home Support Managers.
1.5 FTE administration workers.	15 Home Support Workers.

The Reablement team works with CARS team, North Lanarkshire hospital discharge team, to maximise service users' independence within their own homes. They are developing links with North East Rehabilitation Service, Glasgow hospital discharge team.

Upon receipt of referral OT and Home Support Manager visit service users at home to complete an initial Reablement Assessment, establish service users' outcomes and to set goals with service users. Weekly Reablement Team Meetings are held to discuss service users' progress and set new goals. The Reablement team also have twice weekly handovers to discuss any issues arising, discuss new service users etc.

Outcomes

• 118 service users completed the re-ablement programme between October 2010 and September 2011.
• No service users hours increased
• 21 service users (26%) hours decreased

Services for people with Dementia and Other Mental Health Conditions

Depression, anxiety disorders and dementia are associated with well documented adverse outcomes for older people including increased rates of admission to hospital, increased length of stay in hospital and higher rates of institutionalisation²⁷.

A study by Shah et al in 2000²⁸ in a generic rehabilitation unit for older people, found that only 42% of patients were free from clinically significant symptoms of anxiety, depression or cognitive impairment. There is a real risk that if their psychological needs are not adequately addressed the person may not achieve the rehabilitation outcomes they desire.

The prevalence of dementia and other mental health problems is sufficiently high that all Intermediate Care services should be able to respond positively to patients with these conditions. A number of the Demonstrators²⁹ highlighted positive results from linking with Old Age Psychiatry services and Clinical Psychology, as well as extending the skills of staff working in Intermediate Care services to manage the wide range of conditions that commonly present in older people.

Partnership Example of Good Practice

Early Supported Discharge Team for stroke & orthopaedics

Focuses on patients with elderly care needs and the work of wards 11 & 12 of Aberdeen Royal Infirmary to reduce length of stay within Care of Elderly wards. Starting in the Acute Medical Admissions Unit (AMAU), with a treatment plan that follows the patient, utilising psychiatry services to aid discharge and liaise with community services appropriate to the assessed needs, wherever possible with the aim of discharging the individual back to their own home.

Data available on number of assessment in AMAU, and throughput.