Key lessons and challenges of Intermediate Care

Evidence offers clear learning points that can guide the development of intermediate care.

  1. Local implementation and context impact on success. Areas with a history of effective joint working tend to see more positive results from intermediate care. There is no single one-size-fits-all template for any of the four models of intermediate care.
  2. A more integrated approach to planning, funding and delivery of all four models, including shared assessments that are accepted across all services, is likely to achieve better use of resources and outcomes. Currently, the four service models of intermediate care usually operate separately, delivered by different staff and funded from different budgets. (See Key elements of an effective system).
  3. Capacity should be planned across the whole patient flow. There should be a balance between ‘step-up’ services (designed to prevent hospital admissions) and ‘step-down’ services (to enable timely hospital discharge). Step-up capacity is essential to support admission avoidance but can come under pressure as places are filled with people stepping down from hospital.
  4. The aims, objectives and purpose of intermediate care should be clear and understood by people using the services, their families, and professionals from the wider health and social care system. There can be confusion between services funded through the NHS and reablement services funded by local authorities. The difference between active rehabilitation and reablement and other forms of intermediate care are not always understood, nor the time-limited duration of the service. Unless explained clearly, families may resist discharge from acute hospital and hospital staff may see discharge to long-term care as the only option.
  5. Multi-disciplinary working requires the right staff and skill mix, and flexibility in how staff are deployed across the four types of intermediate care. Multidisciplinary teams should include: nurses, therapists, social workers and community psychiatric nurses, input from voluntary and community groups, and be led by a senior clinician or social worker.
  6. Effective leadership is crucial to deliver clarity of shared purpose about intermediate care across the system and drive the development of the service as part of wider transformation plans, not as a separate standalone initiative. Leadership is needed at senior and operational level in the NHS and local authorities. Both involve a ‘system leadership’ role in overseeing how different service models operate as a single, joined-up service.
  7. New funding and payment mechanisms are available. The roll-out of new models of care through the Vanguard programme and the development of accountable care systems creates opportunities to consider new mechanisms for intermediate care such as capitated budgets for a whole population, pooled health and social care budgets and ‘year of care’ commissioning.
  8. Expectations about what intermediate care can achieve, at what cost and over what timescale, should be realistic. Shifting care out of hospitals is difficult to do and poorly designed intermediate might fuel more demand by revealing unmet need. Care outside of hospital generally is unlikely to be cheaper for the NHS in the short to medium term.
     

Key elements of an effective system

  • A single point of access for all types of local intermediate care services, including a referral process that is widely understood across the whole system and a single assessment process.
  • Shared access to health and social care records – ideally single patient record.
  • A single management structure for the service as a whole and individual elements within it.
  • An agreed multidisciplinary team composition in which staff are able to work flexibly across services and undertake transdisciplinary roles.
  • Joint training and induction programme for health and social care staff.
  • Weekly multidisciplinary team meetings attended by health and social care staff.
  • A mental health specialist included in the establishment of the service.
  • A joint or integrated commissioning function for the service in which health and social care resources are aligned, if not pooled.
  • A single performance management framework.

Support from SCIE

SCIE carries out reviews and evaluations of local areas’ strategies and plans for service transformation, including intermediate care, drawing on the latest evidence of what works.

Our support includes:

  • reviewing proposals for system and service transformation in relation to national best practice
  • analysing and segmenting data to identify the current state of service performance and demand for services
  • conducting cost-benefit analysis to establish the potential cost savings and cost avoidance to the whole system
  • working collaboratively with local stakeholders and people who use services and carers to re-design services
  • producing actionable recommendations.
  • SCIE also provides CPD-accredited training.

Find out more about support from SCIE