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

7. Service Design and Delivery

The description of any service usually makes more sense when presented from the perspective of the people who will use it. When expressed in this way, the design more easily meets an agreed range of needs and positively contributes to rehabilitation, recovery and to carers being able to continue in caring roles.

This section of the framework uses a number of scenarios that illustrate the key responses required to meet personal outcomes, - these are only for guidance and are not exhaustive.

These scenarios should be used to assess current capability and therefore guide local service changes required.

The key questions are:

• What is the service user experience in this area?
• Can the local system meet the personal outcomes described?

These questions and scenarios are not intended to be a substitute for on-going engagement with service users and their families. However they illustrate the key features of successful Intermediate Care through common situations that many will identify with. It is recognised that there are different ways to ensure the outcomes are met and these will differ across the partnerships e.g. city and rural situations may respond in different ways.

The Scenarios

Alice is frail and has a fall at home in out of hours period.

Alice is a 78 year old lady who lives alone and has twice daily visits from home carers to help with personal care. She also has family support close by and a network of friends in the local community. Her home has some adaptations and she has community equipment including toilet frame and personal alarm.

Alice has short term memory loss, is unsteady on her feet and starting to experience falls at home. She also has a history of Urinary tract infections. However she is very much in control of her life and wishes to retain this independence.

Alice had a fall on a Friday evening resulting in a head injury. She did not lose consciousness and calls her neighbour for help. Her neighbour is quick to respond to this incident and calls an ambulance.

The Personal Outcomes that have been expressed by Alice are:

• To avoid hospital admission
• To receive best medical care
• That with her family, she will be fully involved in decisions
• To be supported to recover fully - "to be as good as she can be"
• Clear and consistent information that is shared with herself, her family and her GP
• To have a plan made for any future ill heath episode, so that her views are known and any future response is in line with those wishes

How could Intermediate Care respond?

Initial Triage and Diagnosis

• Scottish Ambulance Service, using one access point, have an established care pathway that includes contacting Intermediate Care in OOH period for response and / or advice.
• Pathways are in place to provide a short hospital stay (maximum overnight) to ensure x-ray and other medical investigations are carried out.

Assessment and medical care planning

• Acute Receiving Unit(s) have access to Intermediate Care OOHs to ensure timely discharge.
• The ability to provide home based care and support overnight could include voluntary organisations, independent sector or statutory providers.

Multi-disciplinary Team response

• One person to coordinate care across the whole system, in line with identified needs and family support available.
• Carry out a 'multifactorial falls risk assessment' to identify modifiable, contributory factors to the fall and gather a full falls history. The assessment should consider Alice's mobility; home environment; ability to carry out daily activities; need for medication review; postural hypotension; feet and footwear; vision; fear of falling/reduced confidence, and cognition etc.
• Access to Allied Health Professionals, home care and nursing team, working in an integrated model - enhancing existing care arrangements rather than replacing. This could include re- ablement home care for a short period.
• Medical or specialist nursing follow up closely aligned to wider Intermediate Care Service

"To be as good as she can be"

• Personalised falls prevention programme is developed, based on the risk assessment findings, and specific goals are set, in discussion with Alice.
• Information on falls prevention is provided in an appropriate format. This includes a range of balance exercises that can be done at home or as part of a group, and will continue after the Intermediate Care period has ended.
• Anticipatory Care plan should be put in place taking into account health and home situation based on personal outcomes.

Time line - How was it for Alice?

See Partnership Example of Good Practice from the Edinburgh Falls Emergency Pathway

Bobby is an 82 year old identified as being at risk via his PEONY V2

Bobby's GP Practice are part of a' Virtual Ward' Local Enhanced Service to test and develop a model of early intervention. Bobby was identified through the use of a Risk Stratification Tool - PEONY 2. This scores the GP practice population who are over 40 years and have a long term condition against their risk of unplanned admission to hospital in the coming year. Bobby's score was 19% (medium risk). Patients with risk scores between 14%-23% are the group for whom early intervention can have the best outcome in terms of prevention of unnecessary admission.

Bobby lives alone and following a fall at home and some investigations, his GP became been concerned about his medication compliance and felt there was some degree of cognitive impairment. Bobby also suffers from COPD, Type 2 Diabetes and a recent onset of hypertension. His only family are a brother and sister who live out of town; he has no social service input or help at home.

Personal outcomes expressed by Bobby are:

• To stay in his own home
• To look after himself
• Keep his garden

How could Intermediate Care respond?

Multi-disciplinary case review

• A multi discipline/agency review of Bobby's current situation is held in a 'ward round' format using CISCO technology. Those present in the Multi disciplinary Team (MDT) include:
  Bobby's GP
  Practice Pharmacist
  District Nurse
  Social Work
  Community Mental Health Nurse
  Community Rehabilitation - the AHP Team
  Medicine for the Elderly (MfE) Consultant

• District Nurse (DN) carried out an initial assessment at home and discovered that Bobby was stock piling his medication, and had stopped taking them as he was unsure of their purpose.

Immediate actions

• All old medication was removed from the house
• Practice Pharmacist carried out a level three face to face medication review
• Bobby was referred for a Community Occupational Therapist assessment
• Bobby was keen to consider the Council gardening service
• Welfare / Benefits check

Multi-disciplinary response

• Practice Pharmacist and DN to monitor Bobby's medication concordance. The outcome of this was that diuretics were commenced and the DN monitored the BP until this stabilised and regularly checked his blood glucose
• The DN arranged to meet a Welfare Rights worker in the home with the aim of gaining information in order to maximise Bobby's income.
• Bobby consented to a referral to social work for assistance with his finances and to other agencies that he would benefit from.
• OT referral resulted in a hand rail for his stairs and bathing aids.
• Meals on wheels service commenced and a Vena link for his medications is now in place and a Key Safe was installed for access into his home. His Brother was successful in gaining power of attorney.

Care Planning

• Bobby has an Anticipatory Care Plan in place, he has discussed his wishes for the future with his brother
• Medication review is completed
• Bobby's Diabetes, COPD & Hypertension will be monitored by the General Practice Team & DN

Time line - How was it for Bobby?

Partnership Example of Good Practice

Dundee Virtual Ward

Dundee CHP and Dundee City Council have worked in partnership to test a model of 'Virtual Wards' with 4 GP test sites.

Medicine for the Elderly and the wider Primary Care teams are working together to identify Older People before unplanned care is required to ensure Polypharmacy issues are addressed, to ensure Anticipatory Care Plans are in place, and that social support is offered to both the older person and their carer.

The learning will be rolled-out as an 'early intervention model' within the wider Integrated Community Services model.

See Partnership Example of Good Practice from the Perth & Kinross Transitional Care at Home Team

Christine is living with Multiple Sclerosis, and is experiencing a period of unexplained ill health and functional decline.

Christine is a 65 yr old, wheelchair bound lady who has been living with Multiple Sclerosis for many years. She lives alone in a remote community, with support. Her daughter lives in Australia. She has homecare visits 4 times each day to help with daily living activities and personal care.

Christine's home has been adapted to meet her needs including provision of equipment. She also visits a day centre once each week.

Her carers start to notice a change in her energy levels and ability to do certain tasks. She also became confused and took the wrong medication on one occasion, after they had been changed by GP.

The home care staff decide to call the GP …

Personal Outcomes expressed by Christine

• To stay in her own home with the carers who understand her daily routines
• Have contact with family overseas, ensuring they are involved in care.
• Not feel so isolated
• To feel well, and have more energy
• To have a plan in place should health and function deteriorate
• To have one person who knows her well and will coordinate care making sure ensure personal outcomes are met.

How could Intermediate Care respond?

Hospital at Home

• Hospital at Home team to can provide a full medical assessment, care plan and follow up treatment or support.

Telecare

• Telecare solutions can be put in place to ensure contact can be made with her daughter on regular basis.

Anticipatory Care Plan

• A Care Manager is allocated permanently to ensure that a relationship is built, and carries out a full personal outcomes based assessment. This assessment, along with the initial medical assessment is included in the ACP to ensure future care needs are addressed quickly, and in a way that meets desired outcomes.

Time line - How was it for Christine?

Partnership Example of Good Practice

DART (Duty & Response Team): East Lothian Council

DART consists of an Occupational Therapist, Physiotherapist, Social Work staff, and Community Care Assistants. The team respond to emergency and urgent referrals with a view to preventing hospital admissions by monitoring individuals at home. Following assessment appropriate advice, care services and equipment is provided within the home, including simple rehabilitation.

See Partnership Example of Good Practice from Dumfries & Galloway STARS service

Daisy is an elderly lady with dementia, who develops an acute health problem

Daisy is a frail 80 year old with dementia. She lives with her 85 year old husband, Bert who is her main carer and is clear that he wants to continue in his caring role without assistance. Their family live close by and want to ensure that their parents stay together, in their own home for as long as possible, but are feeling the pressure of supporting parents without outside help.

Bert has noticed that his wife is becoming more and more aggressive, unsteady on her feet and just seems "unwell". On one occasion Daisy also tried to leave her home in the early hours of the morning. The family also noticed that she needs more help with daily living tasks.

Feeling that he can no longer cope without help Bert calls his GP at 4pm on a Friday.

Personal Outcomes expressed by Daisy and Bert

• To be able to stay at home where she feels safe.
• To feel calm and well again
• Carer and family feel able to cope
• Have a plan for the future
• One contact for the family - someone who knows the situation and they do not have to tell their story to again and again.

How could Intermediate Care respond?

To be able to stay at home, and feel calm and well again

• Hospital at home (Geriatrician and Specialist Nurse) available out of hours through a single access point to assess for delirium. Treatment within the home (including IV antibiotics) can be provided by the hospital at home scheme.
• Access to pharmacy supplies available out of hours, to ensure medication can be provided as soon as possible. Access to psychological support services should also be available as soon as possible, to ensure longer term psychological needs are assessed and addressed.

Carer and family able to cope

• Overnight care could be provided by suitably experienced home care support staff to provide extra support for family carers. Family also directed to the local carers centre for extra help and support over the longer term.

Have a plan for the future

• A Designated Case Manager keeps contact with Daisy and Bert, and ensure their personal outcomes are met. The Case Manager will also complete an anticipatory care plan, recording all decisions on the Intermediate Care provided, and any longer term care needs, such as psychological support. GP also kept well informed and involved in decision making.

Time line - How was it for Daisy & Bert?

Partnership Example of Good Practice

Intermediate Care: Stirling Council

Stirling Council have developed a range of Intermediate Care services under a single management structure. The services include:

• a residential unit within Beech Gardens Care Home;
• rehabilitation at home;
• Crisis care;
• MECS (Mobile Emergency Care Service (Community Alarm)), and
• Therapeutic day care

Service users are able to tap in and out of the different services when needed, and strong links have been developed with assessment and care management teams, providing a seamless delivery of services. All services are outcomes focused and goal driven and are provided jointly by REACH Forth Valley and Stirling Council.

For further examples of good practice see East & Midlothian assessment beds; Perth & Kinross TCAHT and Dumfries & Galloway STARS service.

Eddie - is recovering from a stroke, whose housing no longer suits his needs.

Eddie is 70 yrs old, living alone with no immediate family, but with a network of close friends living nearby. He suffered a stroke 2 weeks ago and is recovering in hospital.

Eddie is showing good signs of recovery, but has a right sided weakness, is unable to walk, can sit unaided and is continent. His has speech difficulties but this is improving.

He is expected to continue to improve and is keen to return home as soon as possible.

Eddie's home is currently unsuitable for his needs, requiring major adaptations. Despite this he is keen to leave hospital and continue his recovery and rehabilitation in the community.

Personal Outcomes expressed by Eddie

• To get out of hospital as soon as possible return to his own home
• To receive regular therapy to continue recovery and be fully independent again including communication
• To be in control of his future
• For personal outcomes known and respected.

How could Intermediate Care respond?

Assessment & Discharge Planning

• A full outcomes based assessment is carried out to establish what options are viable, whilst Eddie is recovering in hospital. A Full Multi-Disciplinary Team, including key worker or case manager, experienced in Stroke rehabilitation are involved from the early stages to ensure best recovery.

Housing

• Rapid assessment by community team carried out to establish whether own home can be used in recovery phase. Alternatives, such as Intermediate Care housing within a sheltered housing unit, or care home should be available if own home is unsuitable.
• Housing and Occupational Therapy teams are fully involved from the outset to ensure any equipment or adaptations required are actioned immediately.

Voluntary Sector contribution

• Links are made with a local voluntary organisation that can provide support and companionship for Eddie when he returns home. Specialising in stroke they are able to help Eddie understand the condition and continue to recover at his own pace at home.

Time line - How was it for Eddie?

Partnership Example of Good Practice

Intermediate Care Hub: Perth & Kinross

Perth & Kinross Intermediate Care Hub provides a single point of access in Perth City, to the community rehabilitation team and discharge services. The team assists in the management of delayed discharges, and can help to facilitate faster discharge and provide prompt access to rehabilitation services. Rapid access older people's assessment is also provided at Simpson's Day Hospital.

Future developments include:

• Intermediate care hubs in North & south localities;
• Build on Intermediate Care beds (step-down) and an Intermediate Care discharge service;
• Outreach Geriatrician/specialist nurse service to support hubs, case management and crisis care;
• Psychiatry of Old Age liaison team
• Early identification of patients with dementia
• SCO support to facilitate early discharge for dementia patients from acute