The service aims to reduce social isolation and support individuals to establish/ re-establish sustainable connections with their communities. People coming to the service have often lost confidence after a fall, illness or bereavement.
The issue we wanted to address was to expand the range of tiered interventions accessible to older people at key points of transition, recognising the limitations of the pre-existing service system. Gap analysis highlighted the need to create alternative inputs in circumstances where:
the older person has had a hospital admission and is clinically ready to leave hospital but requires time to rebuild confidence and regain abilities in a reablement/enablement approach
the older person is at home and due to deterioration in health and wellbeing is at risk of avoidable admission to hospital, the newly developed intermediate care model being able to offer safe care with a lower tariff intervention
the older person is at home and due to deterioration in health and wellbeing or to a change in their social circumstances, [frequently this has taken the form of emergence of adult protection concerns] is at risk of crisis-driven avoidable admission to a mainstream permanent care home. The newly developed intermediate care model is able to offer assessment and a reablement approach which enables more effective care planning and decision making in a less pressured environment and context.
short term support is needed because the carer is unexpectedly temporarily unable to continue in the caring role
planned regular short breaks are required to provide stability, contributing to prevention of unscheduled / crisis triggered transitions.