Intermediate care

Maximising independence at home and improving the pathway from home to hospital and back are at the heart of the 2020 Vision and health and social care integration.

Maximising Recovery, Promoting Independence: An Intermediate Care Framework for Scotland describes intermediate care as a continuum of integrated community services for assessment, treatment, rehabilitation and support for older people and adults with long term conditions at times of transition in their health and support needs.

Framework pic

Intermediate care reduces demand and improves outcomes through:

  • alternatives to emergency admission
  • enabling timely discharge
  • reablement and return to independence
  • reducing premature admission to long-term residential care.

Building the right capacity and capability for Intermediate Care should be a key element of Strategic Commissioning and Unscheduled Care Plans.

Most intermediate care will be provided at home. However some people, particularly those who need alternative housing or major adaptations, may benefit from bed based Intermediate Care to provide critical time and the right environment to recover confidence and independence, and avoid a premature move to long term residential care.

Supporting Improvement

The overall aim by Dec 2015 is for all Partnerships to provide urgent 7 day access to safe and effective alternatives to emergency admission, and enabling support and care to return home from hospital, or closer to home without delay.

JITSs support for Intermediate Care includes:

Intermediate Care Community of Practicepeer support and shared learning through regular learning events, webex and a knowledge portal that hosts case studies, good practice examples, digital stories, service protocols and evaluations.

For IC Section

Benchmarking project with ISD and the Scottish Health and Social Care Benchmarking Network to evidence activity, outcomes and impact.

Surveys of practitioner learning and support needs

Competency Framework for nurses and AHP working in Hospital at Home

 

For IC Section JIT

 

Making the Right Call for a Fall resource for paramedics and falls teams to improve triage, assessment and referral of people who fall in the community.

Making Right Call for a Fall

 

Guidance on developing Integrated Discharge Hubs

The use of technology for remote monitoring and risk assessment in partnership with the Technology Enabled Care programme

Work with Unscheduled Care services and Out of Hours providers to develop Single Point of Access and decision support models.

For further information contact

Dr Anne Hendry, National Clinical lead for Integrated Care anne.hendry@scotland.gsi.gov.uk

Marie Curran, JIT Improvement lead for Intermediate Care   tonmar@sky.com