Intermediate care

Dr Esther Clift is Chair of the BGS NAHP Council, consultant practitioner in Frailty, National Specialty Advisor for NHSE intermediate care with Urgent and Emergency Care and senior lecturer at University of Winchester (Advanced Practice, community and primary care). She tweets @EstherClift

If you want beds, go to IKEA. If you want to ensure older people who have been acutely unwell are supported to recover, then you need services that facilitate rehabilitation, reablement and recovery. For this, you require integrated systems with adequate therapy provision. Targeted, tailored and personalised rehabilitation enables functional recovery.

With the winter months fast approaching, systems are considering how they reduce the number of older people being admitted to hospital - and ensure that those who are admitted have the shortest stay possible, are helped to recover afterwards and are not readmitted.

The Government focus on this issue is gratifying, with additional funding being made available to support systems through the winter months. The NHS England Urgent and Emergency Care Recovery Plan promised £1billion and aims to bolster capacity by ensuring that there are faster ambulance responses, greater virtual ward (hospital at home) capacity, and fewer patients stranded in hospital who could be better cared for at or nearer to home. An additional £200million has since been promised to help services this winter. It is crucial that systems act now to plan how they will use this additional funding, and ensure that this winter is better for older people with frailty than last winter.

Of course, if discharging people home, or to a preferred place of care out of hospital, was simple and straightforward - easy, even - we would all be doing it, wouldn’t we?

Challenges

Our scarce rehabilitation beds are invariably filled with older people for whom this is not the most effective form of care, or simply have nowhere else to go. And we know that people living with frailty are often caught in the quagmire of trying to get home.

The complexity of negotiations between various inter-Trust services, where historic boundaries or silos seem to determine most patients to be ineligible rather than included, makes it all very challenging. We also know that many services do not currently have the resource to provide routine rehabilitation to older people being discharged from hospital. As a result of the implementation of Urgent Community Response (UCR) in England, some services have had to change their workforce focus to meeting the two-hour crisis response target. This has been to the detriment of routine rehabilitation, as meeting the UCR requirements has taken capacity away from the provision of rehabilitation. This has impacted on workforce attrition (UCR isn’t every therapist’s bag) as well as lengthening waiting lists – resulting in patients deteriorating functionally and ending up needing UCR services, which is frustrating, costly and impacts on patients’ quality of life. Investment in routine, or proactive, therapeutic interventions will prevent urgent and emergency presentations. However many systems do not have the workforce in place to deliver this sort of intervention in a timely or therapeutic way.

The recently published Intermediate care framework for rehabilitation, reablement and recovery following hospital discharge offers good practice guidance for Integrated Care Boards (ICBs) intended to help smooth some of the system working barriers, and enhance the capability of the whole workforce beyond hospital provision. In addition to my role as Chair of the BGS Nurse and AHP Council, I have an advisory role at NHS England and was involved in the development of this framework.

Intermediate care framework priorities

The framework’s top priority of improving demand and capacity planning for community systems is intended to be aspirational. Monitoring and reporting capacity in community bedded care is critical to system flow and the goal of a ‘home first’ strategy is laudable. However, it is acknowledged that this can be problematic where health and care systems are not integrated, as often both are needed at the same time. This is where shared care and close working relationships are absolutely essential.

The second priority area describes improved workforce utilisation in the intermediate care space. The accompanying document describing A new community rehabilitation and reablement model endorses the aspiration for therapy-led rehabilitation for people discharged from hospital wards, as well as hospital at home services.

The aspiration for dynamic workforce planning and training for rehabilitation is hard to achieve where there is little provision or funding for training, and certainly no allocated backfill to release staff for training. Some solutions might include:

• Funded places for Masters level modules, from both Trusts and ICBs
• Trusts’ own learning hubs for supporting CPD, which registered and unregistered staff can access
• Using comprehensive geriatric assessment (CGA) and frailty assessment tools to support goal-setting.
• Taking advantage of the recently re-launched and freely available BGS frailty e-learning module, which is an incredible resource.

This all sits within a culture of shared care, trusted referrals, and working together in a seamless system – which is hugely challenging where there are competitive cultures, animosity over long held hierarchies, or finance squabbles.

The proposed ‘Single Point of Access’ for each system or ‘transfer of care’ hubs in priority three may go some way to aiding flow to ensure each patient is in the right place. We need to see genuine integration of our working. We should have currency with housing and social care, as well as senior clinical decision-makers. These colleagues know the details and capability of the home-facing services, helping to support the right people to be in the right place so care needs are met.

Priority four concerns data quality. Capturing of data around UCR work has offered the possibility of describing the services which are delivered (if the data is accurate) and beginning to describe the capacity of the service, what the demand is, and any areas of process efficiencies, where there may be overlap or repetition. Capturing accurate data is about the process, and the mechanism. This needs to be as close to the patient as possible, and simple to use. Apps which clinicians can access when out and about can be really helpful to improve the quality of data captured.

Getting it right for everyone

Therapy colleagues who sit in both health and social care may be our secret weapon when it comes to supporting efficiency and reducing duplication. Integration of services and smoothing of transfers of care, with easy-to-use IT and reliable systems would enhance this.

We know that delivering excellent services for older people with complex needs will relieve the pressure on the system and facilitate timely interventions for other parts of the population. More importantly for our patients, it will ensure they can return to their own homes as early as possible in their recovery journey. If we get it right for people with frailty, we get it right for everyone.

Can this all be achieved in time for winter? Most likely not – but it is worth doing what you can to build rehabilitation services into your system. Investing in such services to aid older people’s recovery and independence delivers better health outcomes and is ultimately a more sustainable and efficient use of resources.