Intermediate Care – Fife

What was the issue you were addressing or working on?

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.

What you did?

The Change Fund enabled investment to create an acute geriatric service which assesses and treats people in their own home (Hospital at Home component of ICASS) and investment in supporting staff e.g. allied health professionals.

The ICASS was developed through the Fife Partnership with development led locally by local management groups with representation from all partners.

Each geographical area has a single point of access for health services and staff previously in IRT, CRT, day hospital  and community allied health professional teams are now co-located. In some areas social work teams are co-located with their health colleagues. The three SPOAs adhere to the same processes and procedures to ensure an equitable, consistent approach. Access to Homecare Re-ablement is via a single point of access contact centre in Fife Council.


What were the outcomes - benefits or otherwise?

The outcomes and benefits include:-

  • Integrated intermediate care teams and hospital at home teams established in each CHP area (over 700 referrals per month to ICASS).
  • Better use of resources and skills with some co-location of social work staff. Improved communication and working relationships. Patient and staff satisfaction high and patients receive a more seamless service.
  • Significant contribution to improving patient flow across sectors and services with the added value of an in-reach service into acute settings – around 50 patients per month had a change in their pathway due to the in-reach service.
  • Co-ordinated approach to community hospital admissions. Pan-Fife management of inpatient capacity.
  • Increase in scope of services provided in community and in community hospitals.
  • Early assessment, alternatives to emergency hospital admission, reduced length of stay if admitted to hospital.
  • Dunfermline & West Fife CHP has expanded intermediate care services element to operate on a Saturday.
  • The ICASS Assessment Team providing in-reach to wards in Victoria Hospital commenced in May but this function transferred to the Discharge Hub in Victoria Hospital in August 2013.

A Case Study that illustrates the initiative can be found here


Contacts - to find out more

Claire Dobson, clariedobson@nhs.net 01383 674044