In 2013, pressure to fill up existing intermediate care capacity with patients leaving hospital has risen, but calls in 2012 to double capacity have failed to filter through this year
Pressure to fill intermediate care services with people leaving hospital has increased this year, leaving less capacity for these services to prevent hospital admissions. Too many frail older people are admitted to hospital unnecessarily or spend too long in hospital beds following emergency admission.
‘Evidence from research shows that an average of seven hospital bed days can be saved for every home-based service user’
Intermediate care provides alternative, community based services to enable people to be looked after at home or in a community setting at times when they need additional support.
These services facilitate more efficient patient flows through the health and social care system and are a key component of integrated care systems.
Research shows that an average of seven hospital bed days can be saved for every home based service user and 14 can be saved for every bed based intermediate care user.
What is intermediate care?
Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent to hospital. The services offer a link between hospitals and where people normally live, and between different areas of the health and social care system: community services, hospitals, GPs and social care.
‘Little was known about the current national picture in terms of scale, scope or quality until the National Audit of Intermediate Care in 2012’
There are three main aims of intermediate care: to help people avoid going into hospital unnecessarily; to help people be as independent as possible following a stay in hospital; and to prevent people from having to move into a residential home until they really need to.
The provision of intermediate care services became a national policy in 2001 but, without a fixed service template, each locality developed its own variant of intermediate care.
Little was known about the current national picture in terms of scale, scope or quality, so the first National Audit of Intermediate Care, conducted in 2012, set out to obtain a “bird’s eye view”.
The study was extended in 2013 to cover crisis response and social care reablement services and to incorporate clinical outcome and patient experience measures.
There was a high level of engagement in the 2013 audit, with a total of 92 clinical commissioning groups taking part (either jointly or in clusters). The total number of clinical commissioning groups covered was 107, with 19 local authorities registered separately; 202 providers submitted data for 410 different intermediate care services.
Evidence from the audit suggests some progress with integration between health and social care at the commissioner level. Strategic planning for intermediate care is now undertaken jointly by health and local government by 90 per cent of audit participants (86 per cent in 2012).
‘Intermediate care capacity needed to double to meet potential demand − there is little evidence nationally that this has happened’
In the 2013 audit, intermediate care services were jointly commissioned in 74 per cent of health economies, compared to 58 per cent in 2012. In addition, use of the formal section 75 pooled budget has increased from 21 per cent to 32 per cent.
Multiagency boards are in place in 70 per cent of areas, as compared to 63 per cent in 2012.
Last year, it was calculated that intermediate care capacity needed to double to meet potential demand. With the exception of two CCGs, there is little evidence nationally that this has happened. The pressure to fill up existing intermediate care capacity with patients leaving hospital appears to have increased in 2013.
The step up in bed based capacity, aimed at avoiding admission to hospital, appears to be even more limited than highlighted in 2012. This raises the important question of whether the current scale of intermediate care is sufficient to make an impact on reducing the overall use of acute hospital beds by frail older people.
Case study: Partnership approach to intermediate care
Bristol Primary Care Trust and Bristol City Council developed a partnership approach to providing an intermediate care service that enables a multidisciplinary rapid response to a health or social care crisis.
The service involves assessing, treating and supporting individuals in their own homes to avoid unnecessary and costly admissions to hospital or residential care. Savings of £3.6m per annum have been achieved.
Key features of the system are:
- a joint commissioning plan from the local authority and the clinical commissioning group setting out service requirements;
- a formal partnership between Bristol Community Heath and Bristol Health and Social Care (the local authority provider), with a jointly appointed strategic service manager;
- the local authority reablement service has combined with the joint intermediate care service, achieving a reduction in ongoing social care support on average of 6-7 hours per person, following reablement interventions;
- advanced nurse practitioner roles have been developed;
- community intravenous therapy is being progressed;
- the rapid response service prevents more than 4,000 admissions per year by providing short term interventions in people’s own homes; and
- there has been a 3.3 per cent reduction of people entering long term care in the first quarter of 2013-14.
Quality assurance challenges
Intermediate care services are typically delivered by small local teams. The average number of intermediate care services per provider identified in the 2013 audit was 2.6 services, but some economies have as many as 22 different services involved in provision.
The task of quality assuring all these services is challenging and raises concerns about fragmentation of services, potentially confusing pathways in and out of services, and few economies of scale.
‘There should be closer links and clearer pathways between intermediate care and acute hospitals’
Research has shown that the most effective models for preventing hospital admissions involve identifying potential patients in hospital emergency departments, yet we found that only 3 per cent of home based intermediate care, 1 per cent of reablement and 18 per cent of crisis response referrals came from emergency departments.
This suggests that intermediate care services are not being routinely accessed by emergency department services.
Furthermore, 20 per cent of bed based services reported an average waiting time from referral to commencement of service of four days or more, with two-thirds of service users waiting in acute beds.
These delays could be the result of process and capacity issues, but they represent a lost opportunity to reduce acute lengths of stay, as well as a poor experience for service users, which could affect their rehabilitation.
This suggests that there should be closer links and clearer pathways between intermediate care and acute hospitals.
Skill mix and clinical need
Questions are also raised about the mix of staff disciplines included in intermediate care teams and how medical cover is provided. The nursing skill mix is in line with Royal College of Nursing recommendations for basic, safe care but are below those levels recommended for ideal, good quality care.
Despite prevalence of dementia of between 20 per cent and 31 per cent in the service user age group (the average age of a recipient of intermediate care is 82), mental health workers are rarely included in intermediate care teams and access to specialist mental health skills appears limited in some parts of the system.
‘The challenge of getting commissioning and service provision in intermediate care up to the level of the best performers is ever more urgent’
Most people receiving intermediate care at home or in a care home tend to receive medical cover from their GP and do not necessarily have access to other specialists. Bearing in mind the average age of recipients of intermediate care, the role of comprehensive geriatric assessment should not be underestimated.
Comprehensive geriatric assessment is the gold standard for effective frailty management and is known to reduce mortality, institutionalisation and hospital admission. It requires a fully staffed interdisciplinary team.
Given the uneven and incomplete nature of the teams suggested by the skill mix data from the audit, it is possible that the full benefit of the assessment is not being realised and that outcomes could be better if more complete teams were routinely in place.
As our population ages and pressure on acute hospitals rises, the challenge of getting commissioning and service provision in intermediate care up to the level of the best performers becomes ever more urgent.
Currently, overall capacity is about half of that which is required to optimise the benefits of intermediate care in releasing hospital beds, while pressure to fill capacity with people stepping down from hospital is increasing.
Dr Duncan Forsyth is chair of the National Audit of Intermediate Care steering group and a consultant geriatrician at Cambridge University Hospitals Foundation Trust; Professor John Gladman is professor of the medicine of older people at Queen’s Medical Centre in Nottingham; Claire Holditch is project director of the National Audit of Intermediate Care and director of the NHS Benchmarking Network; and Professor John Young is national clinical director for integration and frail elderly