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Introduction
The rapid expansion of Intermediate Care services in recent years requires a greater commitment from geriatricians to community practice. It would also require appropriate training of specialist registrars (SpR) in geriatric medicine to develop core competencies required for planning and delivering such services as future consultant geriatricians. A survey to ascertain the community training and experience for specialist registrars in elderly-care medicine had suggested inadequacies in the content of their training. In a pioneering step, Wales developed a comprehensive core curriculum of competencies for intermediate care for SpRs in geriatric medicine. Wales has also been the first deanery to start a training programme for intermediate care, with a rotating post of 4-8 months each, as a component of its specialist registrar training in geriatric medicine. This intermediate care curriculum, although designed for SpRs in Wales, has UK-wide relevance.

Background
I was well into the fourth year of my specialist registrar training in geriatric medicine, and yet until then, I had had scant training and experience in community geriatrics. During my annual RITA in November 2006, the RITA committee recommended that I should consider taking up a post as a SpR in intermediate care for 6 months, from February to July 2007. I felt unprepared for the responsibility of assessing and managing ill patients outside an acute hospital.

Intermediate care service models in Gwent
Gwent offers a number of models of intermediate care services according to the local needs - These include:

• A Hospital-at-home scheme at Torfaen providing home-based assessment, diagnostic tests and needs related management.
• Rapid response services as at Blaenau Gwent, Torfaen, Caerphilly and Newport ;
• A community based re-ablement scheme including a joint day hospital / day centre in Blaenau Gwent;
• A community based rehabilitation unit at Mardy Park social services resource centre in Monmouthshire;
• Inpatient Step up/Step down beds e.g. St. Woolos, Tredegar, Blaina, Chepstow, Monmouth and County hospitals;
• Assistive Technology and Telecare facilities.

The Intermediate Care core curriculum
The Wales Intermediate care curriculum 3 aims to provide high quality training in community geriatric medicine to future geriatricians. It offers a very rounded programme covering:

• Acute care in the community,
• Rehabilitation (at home, in residential/nursing home settings and in community hospitals);
• Chronic long-term conditions management;
• Public health/commissioning/joint planning and
• Assistive technology.
  

What was my experience in this post
A typical week in this post includes assessing ill patients in the community setting such as on domiciliary visits, in care homes, day hospitals and rapid access clinics (‘Hot-clinics’) and in community hospitals. In addition we have reviews of patients seen by the clinical nurse assessors including their investigation reports, ACAT operational meetings twice a week, rehabilitation ward rounds, clinical skills teaching sessions to nurse assessors, some sessions as a clinical attachment (e.g. primary care, public health or perhaps a LHB meeting) and an afternoon dedicated to research.

Acute Care in the community
Professor Bim Bhowmick, who is my mentor during this post, initiated and heads the Torfaen intermediate care project termed “Advanced Clinical Assessment Team” (ACAT). This is a nurse-led hospital admission avoidance scheme aimed at patients with acute illness which can be managed at home. ACAT is designed to:

• Visit and assess patients holistically including physical examination in their own homes and in residential/nursing homes,
• Undertake investigations (ECG, oximetry, glucometry, blood tests and arrange for x-rays),
• Formulate a management plan, liaising closely with the GP,
• Refer to emergency social care, voluntary services, therapists and ‘hot clinics’ as appropriate. Referrals are made mainly by GPs and also by district nurses, social workers, therapists, care home staff or by voluntary bodies involved in case work.

I found that assessing an ill patient in the community, in a setting away from a hospital, can be an unnerving experience for someone with training in only hospital medicine. The unfamiliar surroundings, a feeling of being keenly observed, and often a big audience (on one occasion also visiting at the same time: ACAT nurse assessor, Nurse Assistant, District nurse, Social Worker, and the patient’s daughter in addition to the patient and myself, all cramped in a small living room and all observing my every move) makes the task stressful. All this is in addition to the usual problems that our primary care colleagues have always highlighted - no access to details from previous admissions and the limitations of assessing a patient in an earlier phase of their illness (as compared to a patient with a fully evolved disease picture seen later - for example in the Medical Assessment Unit). Previous experience in assessing and discharging patients from A&E and MAU is very useful here, and this may be the reason why the deanery insists on posting only experienced SpRs (year 3 or later) to this post.

With a strong background in hospital medicine, I have had a steep learning curve in community geriatric medicine . I now find the home visits to be very rewarding, for the professional satisfaction they give from managing an acute medical problem in the patient’s own home (Box 1). They require team-working, diplomacy, and leadership to coordinate a team of colleagues in primary and secondary care, social services, care agencies, and voluntary organisations. Moreover, I found that patients and their families are, almost always, immensely grateful for our role in preventing an acute hospital admission. I remember one particular episode where the clinical nurse assessor from the ACAT Team and I met the G.P. in the patient’s home, to discuss a patient, at the invitation of the G.P. This was a patient with previous multiple strokes who had worsened, rather suddenly, following what appeared to be an episode of aspiration pneumonia. We, from the ACAT team and the G.P. got together in the patient’s home, discussed with the patient and his family each others’ viewpoints and decided that the best option for the patient was to avoid hospitalization and manage him at home.

Management experience
As the first specialist registrar attached to a developing Intermediate Care scheme, I have gained extensive experience from shadowing Professor Bhowmick during its initial commissioning stages and during subsequent troubleshooting. The intermediate care curriculum requires us to attend local health board meetings ( Box 2 ) and clinical attachments to other departments such as Public Health and Social Services. In addition to providing an insight into NHS management, this curriculum has also helped me to an early start in preparing for a consultant’s interview.

Audit and Research
Community geriatrics provides a wide scope for audit and research. I have completed a project on ‘A study of unmet health needs in a residential home’. This particular residential home used to have unusually frequent acute hospital admissions and call-outs to GPs as compared to other care homes. This study aims to investigate if these incidents could be prevented in future. I have now started on another project to see why there are so many emergency transfers to acute hospitals from a particular community hospital in the area.

The curriculum and the paper work
My initial impressions about what was expected of me for my appraisal, was that the curriculum appeared to be daunting and the paper work disproportionate to other subspecialties in geriatric medicine curriculum. Happily, this turned out to be a false alarm in my case as the appraisal process was flexible (Box 3) about the sections in the curriculum that were impractical and the rest was almost enjoyable.

What did I learn during this post
I learnt some important lessons during this post:

• Old and very old persons usually prefer to avoid a hospital admission unless it is absolutely essential.
• A significant proportion of acute hospital admissions are unnecessary.
• Acute hospital admissions can be avoided by bringing facilities for assessment and basic diagnostics at home and liaising closely with the G.P.s.
• Holistic assessment of ill older adults, including systematic physical examination, can be carried out effectively in the community.
• Preliminary work up of ill patients can be done by trained specialist nurses.
• A consultant or senior SpR level support and back up are essential for intermediate care services aiming to safely prevent acute hospital admissions or to facilitate early discharge.
• These services are popular with patients and relatives, well appreciated by the G.P.s and the staff morale is high.
• There is opportunity and scope to undertake research and audit in the community.

 In conclusion
I found this post a very positive experience enabling me to obtain a feel for geriatric medicine in the community. As a specialist registrar in intermediate care, I have had the excellent opportunity to lead a team under supervision, to assess ill patients on domiciliary visits and to gain confidence in making difficult decisions on their management. This curriculum also gave me a useful opportunity for management experience, and an insight into the NHS management structure and its decision-making process - an opportunity not otherwise obtained previously during my SpR training.

References
Intermediate Care, Guidance for Commissioners and Providers of Health and Social Care
(revised 2004 ) BGS Compendium Document 4.2

Young JB, Philip I. Future directions for geriatric medicine. BMJ 2000; 320: 133-4

RCP London . Medical aspects of intermediate care. Dec 2002; www.rcplondon.ac.uk/

Bansal A, Young J. Letter - A survey of community training and experience for specialist registrars in elderly-care medicine. ageing. oxford journals.org/cgi/reprint/30/6/533.pdf pp533 -544.

British Geriatric Society Newsletter March 2005

Box 1 : A typical day with ACAT during my post as a specialist registrar in Intermediate Care

First thing each morning we meet to discuss several referrals currently undergoing assessment: including the ACAT nurse assessor’s initial review, their laboratory reports, ECGs or X-rays and the team’s plans for the day. Twice a week these meetings get extended into operational meetings followed by a teaching- training session: we discuss all patients seen during the previous half-week and this is followed by a brief discussion, usually by Professor Bhowmick, on a topic relevant to a patient being discussed.

We have 6 specialist nurse assessors in our team: three of whom are very experienced senior nurses, who are skilled in their initial medical assessment of sub-acutely ill patients. The other 3 nurse assessors are undergoing a period of induction and intensive training in clinical examination skills. Soon after our operational meeting, I accompany them to one of the wards for some bed-side teaching of clinical skills. It was the respiratory system examination on this particular day; they are very enthusiastic as usual and I realize that they are already quite skilled in picking up crackles and wheeze.

It has been our policy that all unwell patients seen by our clinical nurse assessors would be reviewed by the medical team in a ‘hot clinic’, day hospital or on a domiciliary visit. Today I review two patients in the ‘hot clinic’ arranged in the local community hospital. One of them who had presented after a fall has symptomatic drug induced postural hypotension and the second patient’s chest x-ray confirms right lower lobe pneumonia. The clinical nurse assessor provides feedback to the GP regarding the patient with postural hypotension whilst I discuss the antibiotic therapy for the patient with pneumonia with his GP.

At lunch time I accompany Professor Bhowmick to the LHB Intermediate Care Steering Committee meeting where they discuss various options for integrating overlapping intermediate care services within the borough.

The Clinical nurse assessors have been out on today’s referrals, and periodically they ring to discuss the provisional care plan for the patients they have assessed. They are concerned about two patients today – both of whom are from care homes - one with worsening congestive cardiac failure and the second with a possible new stroke. I decide to join them in the care homes for a ‘senior- review’.

We discuss options with the patient, their carers and family; liaise with the GP and decide to manage them without hospitalization. Later, I discuss today’s patients with Professor Bhowmick who agrees broadly with our plans for their management and offers some suggestions. I find this new experience of assessing and managing ill patients in the community an extremely rewarding part of community geriatric medicine.

I do another domiciliary visit later today for a 76 years old lady with epigastric pain and an abnormal ECG performed at home. After some persuasion she agreed to get admitted to the hospital. An important part of my training in intermediate care has been the oft-repeated stress on the safety of older people who are being considered for community care ; that important reversible, modifiable or preventable conditions are not missed.

Reference: Mulley G. Reconfiguration of acute services for elderly people. BGS Newsletter. March 2007

Box 2: Some of the meeting that I attended.

Box 3: Core curriculum in intermediate care and the appraisal process