| Email your comments
Download this article in MSWord format
Introduction
Intermediate care services have been developed as a solution to chronic hospital bed shortages that has resulted from demographic transitions, acute care demands and the burden of chronic disease. Older people account for two thirds of general and acute hospital admissions. Admission rates for people over 65 are three times higher than the 16-64 age groups. The National Beds Inquiry found that 20% of bed days for people over 65 would be unnecessary if alternative services were in place.The intermediate care services are provided to patients who do not need to be admitted to hospital but may have health / social care needs, which are met within the patient’s own home or within community facilities. Older people are therefore perceived as the main client groups to benefit from intermediate care and it forms standard three of National Service framework for older people.
Excellent examples of health and social care admission alternative schemes have been tested and developed within Wales. In a pioneering step, Wales has developed a comprehensive core curriculum of competencies for intermediate care for SpRs in geriatric medicine. South Wales has another distinction in this area: It is the first deanery in the U.K. to start a training post in intermediate care as a part SpR training in geriatric medicine.
What is Intermediate care?
Intermediate care is the term used to describe a range of services that are characterised by:
- Services that aim to prevent unnecessary acute hospital admission, support timely discharge from an acute setting, maximise independent living and prevent premature or unnecessary admission to long-term care.
- Time-limited interventions, usually up to six weeks but this is discretionary.
- Intermediate care can be provided in a person's own home or in bed-based services either in community hospitals or in residential and nursing homes.
- These admission alternative schemes stand mid-way between full in-patient hospital care and care in the patient's own home.
Intermediate care service models in Gwent
The intermediate care services in the Gwent are jointly funded by the Trust, Local Health Board and Social Services. They are delivered in partnership between primary and secondary health care, local authority services, in particular social care, and the independent sector. These services are provided free of charge to users, making access to services easier.
Intermediate care is provided by a range of professionals, including general practitioners and hospital doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, and social workers, with support from care assistants trained in rehabilitation, administrative staff and voluntary bodies such as Red Cross and Cross Roads. These schemes provide effective person centered services based on partnership. The team's approach seeks to put the patient at the centre and is driven by the principle of 'right care, right place, and right time' and the emphasis is on holistic care, quality of life and independence. Rapid hospital admission is always available whenever it is needed.
Gwent offers different models of intermediate care services according to the local needs - These include:
- Rapid response services as at Blaenau Gwent, Torfaen, Caerphilly and Newport ;
- A Joint day hospital, day centre and re-ablement scheme in Blaenau Gwent;
- A Community rehabilitation unit at Mardy Park, Monmouthshire;
- A Hospital-at-home scheme at Torfaen providing home-based assessment, diagnostic tests and needs related management with a base for the intermediate care team at County hospital;
- Day services for intermediate care provision including therapy e.g. Chepstow Hospital and St. Woolos Hospital at Newport ;
- Inpatient Step up/Step down beds e.g. St. Woolos, Tredegar, Blaina, Chepstow, Monmouth and County hospitals.
- Assistive Technology and Telecare facilities
Blaenau Gwent model of rapid response scheme (Box 1):
This successful intermediate care project was first introduced in 1999. This is a nurse led service and it has elements of both hospital admission avoidance and facilitating early discharge from the hospital schemes. It has access to intermediate care beds set within a Residential Care environment, and input provided by a Re-ablement Team including Occupational Therapy, Physiotherapy, Therapy Assistants, Care Management and Care Support Workers. They liaise closely with the hospital Discharge Liaison nurses to identify hospital patients suitable for transfer at the optimum time. Rapid and urgent assessment and support are key to the success of this service. The staff pride themselves that this system can reduce the length of a patient's stay and pre-empt admission to a long-term facility where they might otherwise sometimes stay for the rest of their lives.
Blaenau Gwent Joint Day Care & Community Re-ablement scheme ( Box 2 ):
This intermediate care service is a new initiative aimed at providing organized day services by integrating day hospital, day centre and re-ablement schemes. Its success serves as an example of the importance of careful attention needed in the practicalities of planning and resourcing these services, and in the preparation and development of its staff with due recognition of special needs of older people. It incorporates both health and social services and it provides people with more flexible support with Rehabilitation and Re-ablement in the community. This pioneering project has won the Queens Nursing Institute Innovative & Creative Practice Award in 2001.
Mardy Park Rehabilitation Project ( Box 3 ):
This rehabilitation project was started in December 2000 as a partnership scheme with Monmouthshire LHB, Gwent Health Trust and Monmouthshire Social and Housing Services. This community rehabilitation unit offers patients a ‘half way house’ on their journey from hospital to home. It is based in a Residential Home in Abergavenny, and provides rehabilitation service for 2 to 4 weeks focusing on the re-enablement of older people following a hospital episode of care. Patients are assessed by a multidisciplinary team including patient’s own GP, District nurse, therapists and a social worker.
Torfaen model of intermediate care:
Torfaen has recently commissioned an innovative intermediate care project termed “Advanced Clinical Assessment Team” (ACAT) headed by Professor Bim Bhowmick. This is a nurse led hospital admission avoidance scheme aimed at patients who do not need immediate acute hospital admission and can be managed at home.
ACAT is able to:
- Visit and assess patients with systematic physical examination in their own home and in residential/nursing homes
- Undertake investigations (ECG, oximetry, glucometry, blood tests and arrange for x-rays)
- Formulate action plan in discussion with GP
- Refer to emergency social care, voluntary services, therapists and hot clinics as appropriate.
Referrals are made by mainly GPs and also by district nurses, social workers, therapists, care home staff or by voluntary bodies involved in case work.
Assistive Technology and Telecare in Intermediate Care ( Box 4 ):
Telecare increasingly features within the care packages of people with support needs. It is a means by which care and support can be provided to people with or without other services, through telecommunications technologies in the home. Assistive technology can be defined as a system that enhances the independence of people with cognitive, physical and communicative difficulties. Most equipment is wireless operated, free standing and able to self test, highlighting need for new batteries or replacement. Equipment is monitored by a central base who can verbally respond to alarm calls and check if an intervention is needed.
It includes a wide range of devices, systems, communication methods, mobility devices, safety systems, which are designed to give the person a greater sense of personal freedom and independence. The technology comprises a range of sensors and triggers, automated functions and visual and social aids. It can also be used to monitor various aspects of the household activities (Lifestyle monitoring) as well as health status (Telemedicine). Some examples of ‘Smart’ sensors include: Smoke Detector, Carbon Monoxide Detector, Natural Gas detector and Shut off Valve, High Temperature Detector, Low Temperature Detector, Flood Detector, Bed/chair occupancy sensor, Fall Detector, Enuresis Sensor, Medication reminder/Dispenser, Radio Door contact set.
Different combinations (‘packages’) of telecare sensors and devices are useful with different types of need. e.g. Environmental and security package, Falls management package, Dementia support package, hospital discharge package.
Next steps
- Intermediate care services in Wales need strengthening to meet projected demand. We need bolder versions of intermediate care services with sufficient service capacity consistent with the needs of older people with chronic conditions, including those with cognitive impairment.
- There is a need to extend these facilities to provide out-of-hours service preferably on a 24/7 basis.
- Rapid Response, Hospital-At-Home schemes, Reablement schemes and mainstream health and social care services are capable of greater integration to deliver consistently effective intermediate care across organizational boundaries.
- It would be helpful to have a central point of access and a single point of referral for intermediate care services with a triage system for the whole range of disciplines including occupational therapy and physiotherapy.
- Health and Social Care day services have scope for development to enable older people to receive rapid community based assessment and diagnosis and review as an appropriate alternative to admission to hospital.
- Out of hours nursing services have scope for further development to provide alternatives to hospital admission.
Dr. C. D’Souza, Specialist Registrar in Geriatric & General Medicine, Gwent Healthcare NHS Trust
Dr. P.B. Khanna, Consultant Physician, Care of the Elderly and Chief-Of-Staff: Community Services, Gwent Healthcare NHS Trust
Professor B. Bhowmick OBE, Consultant in Intermediate Care, Gwent Healthcare NHS Trust
Box – 1: RAPID RESPONSE SCHEME (BLAENAU GWENT MODEL)
(Top of Page)
What is it:
- A Nurse led, ‘health–based model’ of intermediate care aimed at avoiding inappropriate acute hospital admission, facilitate early discharge from hospital and prevent premature care home placement
- Also includes COPD homecare scheme ( supervised by a chest physician)
What They Do:
- Initial assessment within 90 minutes of referral ( 08:00 am – 8:00pm ).
- Interventions including: IV antibiotic administration (up to x 3 times a day, rehydration via subcutaneous route in nursing homes.
- Investigations: blood, ECG, oximetry, spirometry
- Chronic disease self-management strategies – COPD, heart failure, diabetes.
- Daily monitoring of patients and evaluation of response to treatment.
- Liaison with other agencies – Social services, voluntary agencies.
- Access to intermediate care beds (4 beds); Re-ablement services; and emergency home care.
Who works in the Team:
- Staffing levels – Total number: 5
- Registered Nurses 4 FTE, Nursing auxiliary x 1(part-time -18 hours)
- Access to: Reablement Team, Social Workers, Voluntary Services, District nurses, and hospital medical teams.
Referral criteria:
- Sub acute illness, not requiring immediate hospitalization
Exclusion criteria:
- Patient lives outside recognised boundaries; Age under 16 years
Source of referral:
- DGH - wards, A&E & MAU: (50%),GPs (20%), therapy Staff, district nurses, social workers, voluntary agencies
Total number referrals per year: (2006/2007):588
Common Conditions seen: Acute infections (e.g. Chest infections, cellulitis), COPD, Falls, stroke, musculoskeletal disorders,
Discharge destination : Home - 95%, Nursing home - 2.5%, Re-hospitalized:2.5%
Funding by: Gwent Healthcare NHS Trust
Box – 2: BLAENAU GWENT JOINT DAY CARE & RE -ABLEMENT SCHEME
(Top of Page)
What is it:
- A therapy led, ‘social model’ of intermediate care aimed at avoiding inappropriate acute hospital admission, facilitate early discharge from hospital and prevent premature care home placement.
What They Do:
- Provide a comprehensive assessment of rehabilitation and Social Care needs by an inter-disciplinary team
- A time-limited period of rehabilitation and Re-ablement at home.
- Short term admission to a step up/step down intermediate care bed.
Who works in the Team:
- Staffing levels- Total number: 16
- OT (2 WTE), Physio (2 WTE), Nurses (1.65 WTE), re- ablement Officers ( 8.6 WTE) and an Administrator (1WTE)
- Access to: Staff grade doctor, SALT, Dietician, Mental Health Nurse, Social Worker
Referral criteria:
- Adults over 18 years age, medically stable
- Require input from at least two professional disciplines: (OT, Physio, Nursing, Speech therapy, Dietetics, Staff Grade doctor)
- Able to comply with the reablement process (e.g. able to answer the door / allow access)
Exclusion criteria:
- Assessed as unsafe to remain at home with/without support from family members
- Significant cognitive impairment
- Patient lives outside recognised boundaries
Source of referral: DGH (37%) Community referrals including community
Hospitals, GPs, therapy Staff, district nurses, social workers, voluntary agencies: 63 %
Total number referrals per year: (2006/07): 531
Common Conditions seen: Falls, stroke, musculoskeletal disorders, general deterioration, social problems
Funding by : Jointly funded by Local Health Board & Social Services
Box – 3: MARDY PARK RE-ABLEMENT SCHEME
(Top of Page)
What is it:
- An 8 bed, therapy-led, residential rehabilitation unit aimed at avoiding inappropriate acute hospital admission, facilitating earlier discharge from hospital, avoiding unnecessary care packages from social services, and preventing premature care home placement.
- It functions as a therapeutic step between hospital discharge and home, when a person may be “medically fit” but not sufficiently independent with activities of daily living.
- Offers a homely non-institutional environment.
- A service model for integrated, “joined up”, local partnership approaches from Health and Local Authorities to issues such as rehabilitation and hospital discharge.
What they do:
- Short term, goal focused rehabilitation in a Local Authority residential home setting.
- Short term community re-ablement programmed following discharge from Mardy Park .
Who works in the Team:
Staffing levels - Total number: 9
Occupational Therapist (37 hours/week), Physiotherapist (0.4 WTE),
5 x Reablement Assistants (30 hour posts) for rehabilitation unit. 2 x Reablement Assistants (25 hour posts) for community re-ablement following discharge from Mardy park.
Access to: G.P.s, District Nurses, Social services, community services, rapid response scheme as required.
Referral criteria:
- Adults over 18, medically stable,
- Needs based assessment by team
Exclusion criteria:
- Significant cognitive problems
- Patient living outside recognized boundaries
Source of referral: DGH/Community Hospitals (90%); Primary Care team or
Social Services (10%)
Total number referrals per year: 128
Average length of stay: 2 weeks
Discharge destination:
Home: 91%, Re-hospitalized: 6%, Residential home: 3%
Funding: Jointly funded by the Monmouthshire Local Health Board and County Council Social and Housing services
Box – 4: TELECARE INITIATIVES IN GWENT
(Top of Page)
Torfaen County Borough Telecare Project. What they do:
- Uses the platform of the Council Community Alarm Centre which has been technologically enhanced to communicate with ‘Smart’ sensors.
- Monitors and provides emergency help if needed, 24 hours a day, 365 days a year with Lifeline service, and to pilot group with Telecare.
- Maintains one of the most comprehensive installations of assistive technology in a ‘Smart’ demonstration house in Torfaen
- Run a variety of training events and materials, to equip staff knowledge and expertise about the range of technology available.
- Introduces frail older people to the technology and matches technology to their needs
Funding by:
This is a partnership project of Torfaen County Borough council Housing Services, Social services and Local Health Board.
Blaenau Gwent Telecare project What they do:
- Maintains a demonstration house in Tredegar
- ASSIST projects supports people with dementia and other vulnerable groups in their own homes by providing telecare technologies
- Provides two dedicated flats to assist with intermediate care programme with lifestyle monitoring in place to monitor the progress of people returning from hospital
Funding by:
Partnership with LHB, Local authority, Housing Association and Care and Repair Blaenau Gwent
Monmouthshire What they do:
- A ‘Smart House’ demonstration flat in Abergavenny
- A pilot Telecare project involving twenty older people with a wide variety of needs with Ethics Committee approval
Funding by:
- Partnership: Local authority and Gwent healthcare NHS Trust
|