Published: 31/01/2002, Volume II2, No. 5790 Page 28 29
How well are intermediate care schemes working and how do older patients feel about going into nursing homes for convalescence and rehabilitation?
Sefton health authority and two primary care groups - Bootle and Litherland, and Southport and Formby - have completed a pilot scheme which ran from December 2000 to March 2001.
The scheme, funded from continuing care money, followed on the footsteps of a successful project in Liverpool.
1It has now been extended.
The scheme was based on the main principles of intermediate care, which are to increase the number of older people maintaining independent living at home, improve efficiency and effectiveness of health and social care system and make more effective use of acute, continuing care and longterm care capacity, with an emphasis on user and carer involvement.
2The Department of Health guidance specifies that immediate care should include short-term programmes of rehabilitation in community hospitals, nursing and residential homes, and that typically the client should return home afterwards.
Rehabilitation should include input from nurses, physiotherapists, occupational therapists, psychologists and dieticians, it points out.
The NHS plan promised an extra 5,000 intermediate care beds by 2004. The main idea of the Sefton scheme was to purchase numbers of beds in local, privately owned registered nursing homes that fulfilled intermediate care criteria.
Patients chosen for this scheme had to be registered with a Sefton GP, aged 65 and over, medically stable with identified nursing needs, want to go home, be in need of rehabilitation, and be capable of being discharged with support within four to six weeks.
The aims were to:
provide nursing care on a continuous basis, medical care from GPs, physiotherapy and occupational therapy input, and the required social care;
prevent inappropriate hospital admission and allow earlier discharges of medically stable patients;
help patients to achieve a level of functioning, to enable them to live in their own home with appropriate support;
give community nurses and the emergency response team access to beds in the community;
divert inappropriate admissions from accident and emergency departments.
The scheme bought 30 places in three nursing homes at a cost of£363 a week per bed.Homes were selected according to the availability of beds, the training of staff to provide rehabilitation and the availability of physiotherapy, occupational therapy and social work cover.
A total 118 patients were cared for in the scheme, with an average length of stay of 21 days.
Reasons for admissions included falls, fractures, urinary tract infections, chest infections, depression and inability to cope at home. Twothirds of these patients were discharged to their own home, and the others were transferred to longterm care in a nursing or residential home, or admitted to hospital.
Three GPs provided medical cover for intermediate-care patients in the three nursing homes. Between them they had a total of 439 contacts in four months.Most were requested visits, with some routine visits and telephone consultations, medication reviews and writing discharge letters. The GPs were paid£30 a week per bed.
HA data covering December 2000-March 2001 - the period the scheme was in operation - showed a slight increase in the number of patients over 65 admitted to Aintree University Hospital and Southport General compared with the previous year (total 3,512 in 2000-01, compared to 3,159 in 1999-2000). But there was a decrease in the average length of stay for patients admitted through A&E for each month of the scheme compared with previous years (9.1 days in March 2000-01 as compared to 14.22 days in same month 1999-2000).
But the numbers treated by the scheme were not large enough to draw firm conclusions from this.
Patients' views about different elements of the scheme were collected via questionnaires on their admission and discharge from the scheme.
There was a good response rate to both questionnaires, with 72 patients completing the first one and 61 the second.More than 80 per cent of patients considered the nursing care good or very good both on admission and discharge from the scheme.More than three-quarters of the patients in the scheme said they would rather be in the nursing home for their rehabilitation than in hospital or at home.
The evaluation also included interviews with two HA managers, two PCG managers, four social services managers, two hospital managers, three nursing home managers, nursing home staff, two physiotherapists, two occupational therapists and six GPs, including those involved in the scheme.
These were semi-structured interviews, asking about their interpretation of intermediate care, initial perceptions of the scheme and views on how it had worked.
There were reservations about the initial decision-making and involvement of social services in the process, which some managers felt was rushed. Communication between the PCGs, the HA and staff on the ground was also highlighted as in need of attention.Most people interviewed agreed on the definition of intermediate care, but hospital managers were sceptical about the role of the private sector in meeting the needs.
Nursing homes showed great enthusiasm about teamwork and indicated that there were good working relationships with social workers, occupational therapists and physiotherapists. But they raised concerns about continuity of care when therapists or social workers were not available.
After initial reluctance, social services staff accepted the scheme, but again, had some reservations about elements of continuity of care, availability of occupational therapists and the effect on their workload.
Community nurses were happy to play their part and felt that the scheme helped in relieving hospital pressure.They welcomed it as an alternative to hospital, but believed the time limit of four to six weeks was too short for the rehabilitation of some patients.They also raised questions about confused patients and the limitation of the scheme to people over 65.They would have liked the scheme to be extended to include elderly mentally infirm people.
The three GPs providing care enjoyed their role in the scheme and thought patients benefited from the care provided. But they expressed concern about the availability of therapists.
These GPs had a special interest in the scheme as a basis for bidding to be a personal medical services pilot.
GPs not involved in the scheme suggested that not all nursing homes would be suitable for providing intermediate care.And they raised concerns about the need for nursing home staff to be trained in rehabilitation.They also thought it important that specific GPs should be assigned to nursing homes providing intermediate care.
Initially, patients and their carers had some concerns about nursing homes as providers of short-term rehabilitation.This suggests there is a general perception that nursing homes are only for long-term and terminal care.
There is a need to raise public awareness of care provision outside hospitals.This would eventually lead to a change in the perception of nursing homes as places providing only terminal care. l Lessons from the pilot scheme nThere is a need to look carefully at how decisions are made and the role of the primary care trust.
Issues around communication and continuity between hospital and community staff need to be tackled.
A dedicated therapy staff needs to be involved from the beginning.
The aim of therapists helping clients to reach maximum potential needs to be stressed.
A pilot scheme raises fears that nursing home staff will lose the experience gained in patients' rehabilitation.But the scheme is being repeated this year.
Access to beds for elderly mentally infirm patients should be considered in future plans.
Patients need to be followed up at home for intermediate care to be fully evaluated.
1Last S. Bed spread. HSJ 2000; 110 (5717) : 22-23.
2HSC 2001/01: LAC(2001)Intermediate Care. Department of Health, January 2001.
A pilot scheme involving 30 nursing home places provided intermediate care for 118 elderly people over four months last winter.
The average length of stay was 21 days.
Two-thirds of patients were discharged to their own home.
Patients rated the nursing care highly.
Concerns were raised about the availability of therapists.
Dr Ali Zaatar is research and development manager, Newcastle North Tyneside and Northumberland Mental Health trust. He was previously research and development manager at Sefton health authority.