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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Intermediate Care – Fife

Examples of Practice

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.

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Hospital In Reach

Examples of Practice

  • Identifying Midlothian residents that have been admitted to one of the Edinburgh hospitals.
  • Outcomes focussed assessment to determine if they can facilitate an earlier discharge either to Highbank Intermediate Care facility or home with a package of care and/or rehab.
  • Assessment to facilitate earlier discharge to care homes where appropriate.

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Delivering Choice Programme

Examples of Practice

To identify palliative and end of life care needs in Argyll and Bute –

  1. To understand the gaps in the delivery of palliative and end of life care
  2. To develop and support cross partnership working in the area of palliative and end of life care.
  3. To develop new services and initiatives to improve palliative and end of life care

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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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