Intermediate Care – Step Up, Step Down

What was the issue you were addressing or working on?

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.

What you did?

We initially used Change Fund investment to resource the provision of an adapted GP contract to cover the two care homes.  Two GP practices were appointed, each allocated one care home.  We worked closely with the Community Assessment and Rehabilitation Service [CARS] in the Acute Hospitals to enable identification of people who are in hospital and would potentially benefit from the new service, often with their continued input.  We promoted the new model through our Locality Planning Groups [LPGs] through regular attendance by managers of the new service at the LPGs.  We held a workshop which was attended by a wide range of stakeholders including our JIT buddy.  We liaised closely with the Care Inspectorate to ensure a smooth transition in respect of the regulatory and registration frameworks.

We have focused on building relationships between staff based in the care homes and the range of health professionals who are called upon to offer supports to individual service users/patients.  We have monitored the levels of demand for those external inputs, for example the demand for community nursing in order to be able to plan for future development of the model.

We established a strong connection to housing colleagues reflecting that some of the older people who have been admitted to the intermediate care service wanted to continue living in the community but required to move house, or wanted to return to their existing accommodation, however that accommodation would require to be adapted.

All of the care home staff participated in an adapted programme of the Reablement training which we had earlier developed for our Home Support staff.  Staff also undertook training in outcomes focused practice.  We recognised that a Human Resource Development approach was of critical importance in the context that staff needed support to make the transition from the very different service model with which they were familiar from their previous work in a mainstream Local Authority run residential care environment.

We created facilities in the care homes for service users to test a range of equipment including assistive technologies.  This has enabled people to practise with use of equipment and build confidence with their use prior to making the transition to using equipment and technologies in their own homes.

We incorporated into the model the provision of access to our Locality Link Officer who can support service users with re-engaging with their chosen social networks at the point when they can hopefully  make the transition back to staying in their own homes.

We allocated 33% of capacity to provision of planned respite/short breaks.  We received feedback from carers and the cared for person that they attach a high value to being able to have confirmed future respite reservations, with continuity as to the location of the short break.  For many carers this contrasts with the experience of being unable to pre-book placements of choice because of provider preference to release respite placements for booking at a late date in order to maximise the opportunity to attract permanent placements.

As the development involved a transition from a traditional care home model with a permanent population to a short stay model, we had at the outset engaged with the permanent population around the changes which were about to take place.  We confirmed to those residents who wanted to continue living in their existing home that we would support them do so, while also supporting them to understand that their environment would necessarily change as the new model would be implemented.  At time of writing, a small number of residents continue to live permanently in the two care homes and we have offered them support with the transition.

What were the outcomes - benefits or otherwise?

Using current activity levels as a baseline we are on course to deliver an annualised figure of around 1400 weeks of short stay care, spanning the three strands of step down from hospital intermediate care, step up from community intermediate care and planned short breaks.  Some of the step up placements have prevented admissions to hospital and/or to permanent care homes.  The step up route has improved outcomes for older people for whom adult protection concerns have arisen, by providing an environment in which risk can be assessed and reduced with, in several cases, the person being empowered to return safely home.

We have had feedback from carers and the cared for person that during respite placements they have benefitted from the reablement ethos in the  care home – the person returning from the placement having a higher level of confidence in their own abilities than before the placement.

This Example of Practice is illustrated by the case study of Mr JP here.

Contacts - to find out more

Joe McElholm, Manager Older Adults Services ( 01698 332031