intermediate care

Published: 06/02/2003, Volume II3, No. 5841 Page 28 29

By taking referrals direct from ambulance crews, one intermediate care service helps keep older people in their own homes - even in times of crisis.

Lesley Altoft and Debbie Raven report

It is widely accepted that older people should be cared for in their own homes whenever possible.

But a whole-system approach is needed to make this a reality. It was with this belief that Chiltern and South Bucks primary care trust launched an intermediate care scheme in April 2000 which provides nursing care, physiotherapy, occupational therapy and rehabilitation.

Funding consists of£489,000 from the PCT and£28,000 from social services.

The team, based at Amersham General Hospital, comprises five co-ordinators who are all nurses, 12 care and rehabilitation assistants, a care manager, an occupational therapist, a physiotherapist and an administrator. The scheme has access to one nursing home bed and a total of 50 beds in two community hospitals. Referrals have grown from 34 a month, when the scheme started, to 90 now.

Three-quarters are referred by GPs and community staff, with the remainder coming from hospitals.

Patients can also refer themselves. The average time clients receive support from the service is 13 days.

Since December 2001, the scheme has received direct referrals from Two Shires Ambulance trust.

A total of 12 people, with an average age of 85, have come direct from ambulance crews, and this part of the scheme is considered effective in preventing hospital admissions. Twelve referrals may not seem a huge number, but in this climate every bed counts. And growing awareness of the scheme on the part of GPs has reduced the sort of emergency likely to lead to a call to the ambulance service.

When emergency calls are made to the ambulance service, a crew will assess the patient. If hospital accident and emergency care is not needed, the crew will call the intermediate care co-ordinator, who will arrange for the patient to be assessed at home within two hours and care to be provided within four.

Typical clients referred by ambulance crews include:

A 79-year-old man, who had been discharged from hospital the previous day, fell out of bed and was suffering from leg ulcers, diabetes and breathing difficulties. After referral by the ambulance service, the intermediate care team provided daily physiotherapy and occupational therapy for 16 days after which he regained independence.He was referred to the team again seven months later and, after reassessment, longterm home care was provided by social services and hospital admission was prevented.

An 83-year-old woman suffering from confusion and lethargy was referred by an ambulance crew.

She was visited by the team for two days and then admitted to hospital when her condition deteriorated. Once discharged, the team provided two weeks of rehabilitation and care.

A 79-year-old woman was referred after a fall which left her completely immobile. But after twice-daily visits to provide care and rehabilitation she was able to look after herself. The team often finds that by the time of the emergency, the older person has stopped looking after him or herself. The focus of the care package is always rehabilitation.

An 82-year-old man had been discharged from hospital following a stroke and his wife was having difficulty coping. The intermediate care team immediately referred the case to social services, which provided long-term home care.

All the intermediate care co-ordinators feel the referrals received from the ambulance crews were appropriate and that the information provided was sufficient in the majority of cases. All believed that accepting referrals from the ambulance crews was appropriate and in patients' best interests.

For their part, ambulance staff reported that intermediate care staff were helpful on the telephone. Some ambulance staff would have liked to have been kept informed of the outcome of the referral.A couple of crews commented positively on the fact that the intermediate care team had arrived at the patient's home before the crew left.

Falls and loss of mobility are the main reasons for people being referred to intermediate care by ambulance crews. Another common denominator is carers being unable to cope. This is where intermediate care comes into its own, offering prompt help and keeping people out of hospital. It is possible that providing help within four hours may avoid further injuries.

It is likely that each of the clients referred could have fallen again if no care had been available, which might have led to hospital admission. Such admissions could result in the loss of independence and make institutionalised long-term care a probable outcome.

It might be argued that by keeping people at home, the scheme reduces pressure on accident and emergency departments.

Ambulance crews and members of the intermediate care team have learned to trust each other's clinical judgement and this helped break down professional boundaries.

Initially, ambulance crews were reserved about making referrals, but their confidence has increased.

It is hoped to extend the scheme to operate 24 hours a day by linking it with out-of-hours nursing services.We hope to establish a system for reporting the outcome of referrals back to the ambulance crews and to set up a shadowing scheme so we can understand each other's roles better.We are also developing a system to administer intravenous antibiotics to patients in their own homes.

The government has set out a number ofmodels of intermediate care.These include a rapid response offering short-term nursing, therapy and social care to prevent avoidable acute admissions; intensive support at home, including investigations and treatment; residential rehabilitation in community hospitals or nursing homes; day rehabilitation.

The national service framework for older people suggests that intermediate care should be for six weeks or less. It says intermediate care should be considered when responding to or averting a crisis, as active rehabilitation following an acute hospital stay, and when long-term care is being considered.

Our scheme meets many of these criteria and is extending the period older people can remain in their own homes, with swift response care available in emergencies.

Key points

An intermediate care scheme launched by a primary care trust in April 2000 is now receiving 90 referrals a month, mainly from GPs and community staff.

Patients receive an assessment within two hours of referral and care within four hours.

Patients can refer themselves and ambulance crews can also refer patients to the scheme, preventing hospital admissions.

The scheme operates from 8am to 8pm, seven days a week and it is hoped to extend it to 24 hours.

Lesley Altoft is clinical supervisor, Two Shires Ambulance trust.

Debbie Raven is community hospitals/intermediate care manager, Chiltern and South Bucks primary care trust.