Executive Summary

Intermediate care services are designed to provide alternatives to emergency admission and support early discharges back to the community. Between 5 and 10% of emergency admissions are capable of being streamed into intermediate care schemes from home, or from Accident & Emergency Departments and Medical Admission Units. Significant reductions in bed days occupied could result from timely access to Intermediate Care Schemes, with development of the number, type and range of schemes available supported by allied health professionals, social workers and general practitioners with a special interest in the care of older people. Critical to the process would be early involvement by Geriatricians and Specialist Nurses to enhance decision making.

Introduction

The National Plan [1] and English National Service Framework for Older People [2] set out targets and expectations for a new range of intermediate care services to fill the gap between secondary and primary or community care. The aim is to provide a genuine alternative to hospital admission for some carefully selected patients and to provide supported discharges for others. This will include the provision of opportunity for further assessment and rehabilitation of older people so that no older person is placed in a care home directly from an acute facility. Recent years have seen a major expansion of intermediate care schemes including rapid response teams, community assessment and rehabilitation teams, residential reablement units, hospital at home schemes and a revitalised role for community hospitals. Many services have been developed according to local need but tend to vary in capacity and content between districts. “Step up” functions from the community are regarded by primary care teams as of equal importance to step down facilities.

Current position

The NHS Plan target is for 5000 additional beds to be available by 2004, with 1,700 extra non-residential places benefiting 220,000 people supported by a £900m investment. Older people form the largest client group for intermediate care but schemes exist for younger patients with chronic disease. The British Geriatrics Society [3] is keen to ensure that appropriate medical assessment as an integral part of comprehensive geriatric assessment is available to patients in intermediate care schemes. The Royal College of Physicians [4] recommends medical input from primary and secondary care with appropriate skills and training working within a clinical governance framework.

Evaluation of Intermediate Care Schemes

The evidence base for intermediate care has recently been reviewed. [5] Hospital at home schemes appear to offer a valid alternative to hospital inpatient care for certain categories of patient but there is insufficient evidence at present to evaluate the role of community rehabilitation teams other than those providing specialist stroke services. Evaluations suggest day hospital care is at least equivalent in effectiveness to comprehensive geriatric assessment in traditional settings while evidence of effective outcomes from community hospital care remains lacking. Nurse led units provide a safe alternative to traditional hospital wards but may prolong length of stay. Care home based rehabilitation has not been evaluated and may be limited by low levels of therapy input.

Emergency Care Strategy

Currently a new strategy for reforming emergency care is being formulated where the key theme will be streaming of patients into appropriate care pathways. For older people this is likely to involve early assessment in Accident and Emergency departments, Medical Admissions Units or Acute Wards with entry into pathways for acute stroke, older people with falls, delirium, decreased functional level and mobility problems, plus transfer to intermediate care pathways for those patients who could be managed in alternative settings.

Opportunities for Streaming

Work from East Anglia [6] using a locally derived set of appropriateness criteria (EACHEP tool) suggests that up to 5% of older people presenting as emergencies could be managed in a community hospital setting. The consensus arising from a variety of other schemes is that approximately 10% of acute admissions of older people may be suitable for streaming rapidly into intermediate care. A prospective observational study in Bradford [7] suggested approximately 26% of acute admissions presenting to an elderly care department aged 77 years or over had post-acute care needs. The majority (80%) needed rehabilitation, with the bulk of the remainder requiring new care home placement or recuperation.

Therefore, there is likely to be a role for intermediate care in providing alternatives to admission but the main gains in terms of bed days would be by supporting earlier discharges from acute beds for patients requiring recuperation, patients requiring re-ablement (frequently after a period of specialist inpatient rehabilitation) and patients requiring transitional care while community care packages or new care home placements are agreed and funded. The role of intermediate care in supporting this latter group still needs to be clarified. The needs of patients with significant dementia without behavioural problems should not be excluded from the intermediate care programme.

Implementing Streaming

The key to expanding the role of intermediate care to support emergency services will be the streaming of appropriate patients rapidly into intermediate care services. This will have significant workload and manpower implications arising from the need to commit consultants, nurse specialists and nurse consultants with assessment and diagnostic skills to the process. It will be important to engage PCT’s and local authority social services departments in the process to ensure timely access to intermediate care pathways and avoid tension over use of shared resources. Clear links with the single assessment process should be developed. Intermediate care services will need to have achieved a critical capacity and organisational integrity to support this new A&E function. One advantage of linking intermediate care to A&E is the inherent provision of a medical assessment process to ensure significant acute problems such as fractures or infections are recognised before intermediate care referral. This should improve the clinical safety of the admission avoidance function of intermediate care.

(1) Managing Crises in the Community and at Home

An important element of admission avoidance would be early access to assessment and crisis support in the community. In many districts this is already achieved through:

• Rapid response community teams available 24 hours a day who are able to access appropriate support for home care, urgent respite, hospital at home, palliative care or day hospital attendance.
• Telephone advice for general practitioners/MDT members from duty geriatrician
• Rapid access to day hospital MDT assessment
• Disease specific domiciliary support teams; e.g. COPD, heart failure, Parkinson’s disease
• Referral to General Practitioners with a Specialist Interest in the Care of Older People (GPWSI)

(2) Managing Crises at the Front Door

The key elements would be:

• Early assessment of patients in Medical Admission Units or Accident & Emergency departments possibly by a Nurse Practitioner initially supported by Consultant Geriatrician where requested. This could take place in an observation ward attached to A&E perhaps after a 24-48 hour stay to exclude or identify intercurrent illness.
• Streaming into one of a range of pathways including:
  • Specialist acute wards for older people or other speciality (e.g. orthopaedics, old age psychiatry) or
  • Home care with community team support or
  • Specialist rehabilitation ward for older people. Rehabilitation is a continuous process rather than a facility based activity, so the boundaries between slow stream specialist or complex rehabilitation and intermediate care rehabilitation may be hard to establish and should be regarded as capable of local definition.
  • Community hospital beds
  • Recuperation bed in a nursing home
  • Residential rehabilitation facility or other community scheme
  • Nurse led unit

(3) Managing Post-Acute Phase

The key theme would be a locally derived model of care with clear pathways to ensure early assessment and management of older people in wards of different specialities. This would involve streaming into similar pathways to above at various times as the acute illness/problem settles. The important principle would be timely access to intermediate care facilities such as:

• Recuperation beds; e.g. patients post MI or pneumonia where full functional recovery is anticipated
• Reablement beds; e.g. post surgical neck of femur patient, post delirium patients, post stroke or pneumonia where mobility has improved but daily living skills need further work and future care needs require assessment
• Transitional beds; e.g. patients where new care home placement or larger package of care requires co-ordination or funding
• Home care; e.g. patients with ongoing rehabilitation needs but good home support requiring ongoing input of specialist early discharge community team/hospital at home or modified day hospital (Older Persons Assessment and Rehabilitation Centre)
• Home care by Palliative Care Team
• Falls assessment pathway for recurrent Accident and Emergency attenders
• Intensive community monitoring pathway for patients who are developing problems coping at home where intensive home support for a period of 4-6 weeks may be required to identify future care needs, frequently with mental health input for patients with cognitive problems

By accessing these schemes in more timely fashion significant bed day reduction could be achieved. Work is urgently needed to quantify the numbers of patients who could benefit from early discharge in this way and the impact this could have on acute Lengths of stay.

Addressing Concerns

While community hospitals may be staffed to meet many health needs (although specialist medical input may be suboptimal), residential rehabilitation facilities established in former residential care homes may not be, creating a need to introduce and develop rehabilitation skills. This tends to dilute expertise in secondary care as therapists and nurse specialists take on new roles and challenges in the community. There is already some evidence that the length of stay of patients in intermediate care beds may be greater than similar patients in hospital beds (8) indicating the need to maintain pressure for home discharge. In order to develop the above schemes there will be a need to:

• Recruit and train additional therapists with expertise in dealing with older people
• Recruit and train additional nurse specialists to undertake assessment of acutely ill older person and assess rehabilitation needs (probably 1-2 per 10 5 population)
• Establish new consultant geriatrician posts to support streaming work and extend medical expertise into the community (probably 1 per 10 5 population)
• Expand the number of general practitioners with special interest in Health Care of Older People (GPWSI) to extend the availability of specialist medical input to patients in intermediate care schemes
• Acknowledge the training and development needs of interdisciplinary team members working in intermediate care schemes
• Ensure that intermediate care schemes participate in Clinical Governance programmes including clinical audit, risk assessment and critical incident review
• Clear criteria for entry in to schemes and standards for type and number of interventions within pathways.

References

1. The NHS Plan. Department of Health, London 2000
2. National Service Framework for Older People. Department of Health, London 2001
3. Standards of Care for Specialist Services for Older People. British Geriatrics Society, London 2002
4. Report of the Federation of Royal Colleges of Physicians Working Party on Medical Aspects of Intermediate Care. Royal College of Physicians , London 2003
5. Young J. The evidence base for intermediate care. Geriatric Medicine 2002, 10, 11-14
6. Puliyel M; Maisey D.N; Shepstone L. Developing a model for assessing appropriateness of emergency geriatric admissions. Age and Ageing 2000, 29, supp 1 p34
7. Young J; Forster A; Green J; An Estimate of Post-Acute Intermediate Care Needs in an Elderly Care Department for Older People. Health and Social Care in the Community (in press)
8. Fleming S; Gladman J. Evaluation of a Care Home Rehabilitation Service: Outcomes at 3 months. Age and Ageing 2002, 31, supp 2 p4

Appendix 1

Current Estimates of needs for Intermediate Care in England

Extrapolating from the Bradford data [6] it would appear that for each 100,000 catchment population, approximately 1200 admissions of patients over 75 yrs with functional problems may be expected with approximately 300 requiring post acute care, 250 (80%) of whom will need rehabilitation, and 40 new care home placements. The number not requiring post acute inpatient care and capable of being supported by community team is not known.

Assuming a mean length of stay of 15 days then the number of beds required (at 100% occupancy) in intermediate care would be 12.3 per 10 5 population with appropriate physiotherapy, occupational therapy and SW input. However, unpublished data from East Anglia suggests that including patients requiring rehabilitation from surgical and orthopaedic units, with a mean length of stay of 20 days, then the figure would need to be up to 60 beds per 10 5 population. In Gateshead , the community resource team receives approximately 80 referrals per month from 225,000 catchment population with 25% coming from hospital and 75% from community. This would give a capacity estimate of 427 places per 10 5 population per annum, with appropriate specialist nurse input, in addition to OT/physio and SW contributions.