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.
The aim of establishing ICASS in Fife was to transform community services by bringing together uni-disciplinary teams to utilise fully resources available in line with demand, and to coordinate care through a single point of access (SPOA). It contributes to our commitment to ensure the closer integration of the range of community services under one system.
It aims to improve quality of care and outcomes for older people whilst allowing them to remain independent within their own homes or communities, provides alternatives to hospital admission, reduces the number requiring long term institutional care, reduces length of stay for those who require a hospital admission. It aims to address the following:
Moving from an inpatient model of care to a robust community based model of care involving older people and their carers and families in care planning
Bringing together teams to make more efficient use of resources to meet the needs/demands of the increasingly elderly population
To provide a single point of access
To provide alternatives to hospital admission
To reduce length of stay if an admission is necessary
To provide assessment and care in the person’s own home or a homely setting
To achieve and sustain maximum potential and independence; and
To reduce numbers going into long term institutional care.