Intermediate Care Short Term Assessment in Care Ho

What was the issue you were addressing or working on?

Enhancing Intermediate care pathways and options of care for individuals who are at risk of requiring a care home placement. Particularly those discharged from hospital including those who become or at risk of becoming delayed discharges.

What you did?

Reshaped an additional 20 internal care home beds in Stirling been fully implemented since October 2012.  We have also agreed a plan to do same with a further 4 in Clackmannanshire.

  • The care and management processes and pathways for the IC beds from hospital and the community are now fully agreed and embedded. This has led to significantly increased admissions from hospital and overall model performance as the model has embedded and stabilised.
  • 92 Service Users have been discharged between April 12  & June 13.  64 of these in first 6 months of 2013.

What were the outcomes - benefits or otherwise?

Performance and Outcomes

The overall average Length of stay has been 9 weeks, over the last year. This average has been reducing in recent months.  From the last 48 service users through the model of care the following Discharge Outcomes are noted and sustained at 3 months:  
test table
The graph below shows capacity and balance of discharges to long term care 2011-13:
Intermediate Care in Care Homes Graph

Service User Outcomes

Mr B was admitted for a short stay assessment placement following a serious urinary tract infection where he had been admitted to Forth Valley Royal Hospital from his home.  Upon admission to the short stay unit, his son explained that he was looking into long term care options for his father, believing that he could no longer manage in his own home alone.  With a short period of assessment in Beech Gardens, it was quickly identified that Mr B had rehabilitation potential, and Occupational and Physiotherapists from ReACH commenced a set of goals for him to work towards.  Mr B fully engaged in this process and was able to return home within a timescale of less than 3 weeks.  In this situation, the service was able to provide a short period of support which enabled his return home. With a Reablement based package of care he would be reviewed until it met his longer term outcomes.  This avoided a prolonged stay in hospital, and a hasty decision for long term care, facilitating the gentleman’s desire to return to his own home, and would not have been possible prior to the establishment of short stay assessment placements.

Contacts - to find out more

Linda Melville,