A Compilation of Good Practices – Integrated Care

Resource

European Innovation Partnership on Active Healthy Ageing A Compilation of Good Practices – Integrated Care for Chronic Diseases (2nd edition) This compilation is the product of the collaborative work of the members of the B3 Integrated Care Action Group. In this collective effort, the experts of the Action Group have been pooling their knowledge and […]

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Intermediate Care – Step Up, Step Down

Examples of Practice

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.

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COMPASS

Examples of Practice

The objectives of COMPASS include:

  • To improve the identification of older people in the community at risk of escalation / hospital admission
  • To facilitate and provide proactive case management for those at risk of admission by the most appropriate service
  • To prevent the emergency admission of patients to hospital by facilitating and providing timely access to alternatives within domiciliary, outpatient, Day Hospital and inpatient settings
  • To facilitate the discharge and prevent later readmission of patients from hospital following a planned or emergency admission
  • To provide a point of contact for GPs to seek advice/ discussion with a Medicine of the Elderly (MoE) consultant, with the aim of reducing emergency hospital admissions where possible and appropriate
  • To conduct comprehensive assessment for patients in a range of settings
  • To improve understanding of, and communication between primary, secondary and social care services, leading to better outcomes for individual patients/ service users
  • To identify areas for further improvement, collaboration and joint working and to develop a vision for future ways of working, including a ‘virtual ward’ ‘hospital at home’ model

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