Intermediate care guide

Context for Intermediate Care

Definition

Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent to hospital.

Intermediate care

• helps people to avoid going into hospital or residential care unnecessarily
• helps people to be as independent as possible after a stay in hospital
• can be provided in different places (e.g. community hospital, residential home or in people’s own homes).

Policy context

Intermediate care is not a new idea. Promoting independence and shifting care away from hospitals and residential homes has been a policy objective for over 30 years.

Intermediate care was developed as part of the NHS Plan in 2000 and was one of the national standards in the 2001 National Service Framework Service for Older People.

It is an important focus of efforts to integrate health and social care through the Better Care Fund. It is central to the ambitions of most Sustainability Transformation Plans across the country to shift more care closer to home and to the NHS Five Year Forward View triple aim of better health, better care, and better value.

Models of intermediate care

Four broad service models of intermediate care have evolved:

1. Bed-based services are provided in an acute hospital, community hospital, residential care home, nursing home, standalone intermediate care facility, independent sector facility, local authority facility or other bedbased settings.
2. Community-based services provide assessment and interventions to people in their own home or a care home.
3. Crisis response services are based in the community and are provided to people in their own home or a care home with the aim of avoiding hospital admissions.
4. Reablement services are based in the community and provide assessment and interventions to people in their own home or a care home. These services aim to help people recover skills and confidence to live at home and maximise their independence.

The case for Intermediate Care

There are at least three reasons why the development of intermediate care requires fresh impetus.

More of the same is not sustainable

The health and social care system faces major challenges arising from squeezed budgets, rising demand, increasing costs, greater transparency about the quality of care, and rising public expectations. Levels of hospital activity – especially admissions – have continued to rise over the last eight years.

These pressures will be intensified by demography. The number of people aged 85 and over will increase by a third over the next ten years, and the number of people living with dementia is expected to grow to around 1.3 million in 2025.

One estimate suggests that if admission rates continue to increase, the growing and ageing population alone means that the NHS would need approximately 17,000 additional beds by 2022 (Smith and others, 2014).

Responding to these challenges with ‘more of the same’ – acute hospital beds and care home places – is not sustainable – or the best option for individuals.

Intermediate care offers a more costeffective, if not cheaper, response.

Performance is variable

There are wide variations in the performance of local heath and care systems in offering care closer to home. Intermediate care could make a much bigger difference to people’s experience, outcomes and use of resources.

Key variations between different parts of the country include:

• Emergency hospital admissions of people aged 75 and over varies nine-fold
• Hospital admission of people aged 75 and over from residential care/ nursing homes varies 604-fold
• Admissions to residential care and nursing home of people funded by councils varies six-fold
• The number of people still at home 91 days after being discharged from hospital to a reablement/rehabilitation service varies nine-fold.

Demand for intermediate care is increasing

Investment in intermediate care is not keeping pace with rising need.

Expenditure in recent years has remained static and capacity is around a half of what is required. Reablement capacity is actually falling – despite increasing evidence of its effectiveness – and waiting times for intermediate care are rising (National Audit of Intermediate Care 2015).

As a result, the potential of intermediate care to reduce the pressure on hospitals and social care is under-utilised.

Evidence of effectiveness

Evidence shows that well-designed intermediate care can (03):

• improve people’s outcomes and levels of satisfaction
• reduce admissions to hospital and long term social care services
• reduce delayed discharges.

92% of people who used home-based or reablement services maintained or improved their dependency score (a measure of the help they need with activities of daily living).

93% of people who used bed based services maintained or improved their dependency score.

70% of people who received intermediate care following a hospital stay, were able to return to their own home.

72% of people did not move to a more dependent care setting.

88% of people using health based intermediate care services meet their goals (wholly or partially).

90% of people said they were treated with dignity and respect. There is room for improvement about communicating with and involving people who use services and managing expectation about the short-term nature of the service.

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.

Case studies

About the video

Somerset Care and Yeovil District Hospital work in partnership to provide rehabilitation and reablement in a modern, homely nursing home, Cooksons Court. Hear about what this means for patients, the hospital and the NHS in this short film.

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

Further information on Intermediate Care

The following is a list of resources on intermediate care:

• Homecare reablement toolkit, (2011, archived), Care Services Efficiency Delivery programme, Department of Health
• Intermediate care including reablement (NG74), 2017, National Institute for Health and Care Excellence
• National Audit of Intermediate Care Summary Report (2015), NHS Benchmarking Network
• Prevention and wellbeing, Social Care Institute for Excellence
• Reablement resources, Social Care Institute for Excellence. Includes guide to Maximising the potential of reablement
• Shifting the balance of care: great expectations (2017), Research report. Nuffield Trust

References

1. NHS Benchmarking (2015) National Audit of Intermediate Care Network Report ↵
2. NHS Atlas of Variation 2015 ↵
3. NHS Benchmarking (2015) National Audit of Intermediate Care Network Report ↵