A pilot study of prevention-focused intermediate care services looked to evaluate the approach of engaging with patients and staff as a way to improve efficiency and avoid admissions. Dawne Garrett runs through the results.
Intermediate Care provides a range of national services based on three principles:
- Prevention of people being inappropriately admitted to hospital
- Assisting timely hospital discharge, when admission has been necessary;
- Promotion of good health, enabling people to make informed choices to remain as independent as possible, within their own homes.
Poole Intermediate Care Service was set up to address this agenda as collaboration between community health services, social services and the acute trust. The PICS team is comprised of nurses, GPs, medical consultants, social worker/care managers, intermediate care assistants, administrative staff and a manager.
Despite intensive support by the PICS service some patients had emergency admissions to the acute trust. The study aimed to investigate the factors that cause this and evaluate this method of engaging patients and carers in service evaluation.
- Literature review and initial focus group with staff
- Identification of patients through the weekly virtual ward rounds.
- Case note review-prior to admission and following discharge
- Qualitative interviews with patient, carers and staff one month post discharge
- Data analysis - identification of key factors/themes
A convenience sample of 20 people took part in the study. Identification of patients was through the weekly virtual ward rounds. The patient and carers were invited by letter to participate in the study and then followed up by the principal investigator to confirm whether they would take part. Staff who were involved with the patient were also invited to a separate focus group or individual interview.
The interviews were tape recorded and transcribed verbatim.
Case note review
Case note analysis was performed by a consultant geriatrician with clinical intermediate care experience. A simple proforma was used to summarise and record clinical précis, including co-morbidities, medication, domicile type and social care / support. Conclusions about factors leading to unplanned admission were drawn.
The data was coded and categorised for emergent themes. Due to the principle investigators familiarity with the service the codes were analysed by two independent health care researchers to check interpretation and confirm categories. Through an iterative process the final categories emerged.
This category revealed differing understandings from other healthcare professionals and patients about the role and abilities of the intermediate care team Some staff and patients believed it was perfectly possible to maintain acutely ill patients at home and commented.
Capacity of the service
Unsurprisingly the capacity of the service to respond was an issue. Frequently a staff member was available but the patient’s needs were greater than could be provided by one person.
Quality of clinical assessment
The quality of the clinical assessment and reassessment is key to the planning and treatment, there are tensions in ensuring that the patient receives a proportionate and equitable assessment which is commensurate with the care they would receive as an in patient.
The need to have a transparent pathway and predicted outcome
The nature of community services can mean that many members of differing teams are involved in elements of a patients care at home. The obvious communication difficulties and differing planned outcomes can impact on the smoothness of the patient experience and recovery.
Planning treatment - for the worst not the best
The team work with the aim that interventions will prevent admissions. Assessments are made in a relatively short period of time without the luxury of continual monitoring. Care plans and symptom control interventions can frequently require adjustment. Sometimes the complexity of patient’s condition and co morbidity means that the plans do not cover every eventuality.
A geriatrician summed this up in saying, “but if we are talking about keeping people out of hospital early on when things are difficult to predict, we need to predict at their worst, not their best because it’s at their worst times that they are going to come into hospital.”
Patient and family
A key to helping the family support a patient at home is education. Members of the service are not with patients all the time and family/friends are often required to provide physical care. New devices, equipment and care can cause problems.
For example: “…Also, they just let the husband put a lump of wood under her back because a slide sheet had come in and obviously they’d put the sheet the wrong way round and he put a lump of wood underneath to keep the slide sheet in place. I sort of had to say ‘No’ and not to use the slide sheet without being shown how to use it. They had it the wrong way round.” ICA.
Managing clinical risk
Frequently the assumption that someone’s home can be turned in to the equivalent of the hospital environment was misplaced. Family members may be very concerned
The PICS team are guests in people’s homes whose social mores and behaviour are very different to those of people in hospital. There are professional standards that the team are trying to uphold often in the face of conflicting circumstance.
“I think it’s better without an audience because then you can talk to the patient and they respond better when it’s ‘one-to-one’ rather than a whole group of people together. Not only that but there’s their privacy. It’s not right with the neighbour…” - Nurse
Case note findings
All were complex patients. The fact that their medical problems were inevitably the focus of their assessments in hospital may present bias, but dominant factors driving admission seemed often to relate to medical needs.
Where patients are seriously unwell these needs include urgent assessment and access to the full range of medical/surgical interventions. Some of the cases reviewed fell into this category: service users with septic illnesses complicated by haemodynamic compromise or rapidly deteriorating respiratory failure could be viewed as straightforward medical admissions.
One of the cases concerned an elderly lady with severe chronic obstructive pulmonary disease and dementia, discharged in an oxygen-dependant state to a commissioned step-down nursing home bed after an exacerbation of her airways disease. Later she was admitted, passing away on the care of the dying pathway within a few hours.
The rapid progression of her illness was not easily foreseeable but with hindsight, such an exacerbation could have been anticipated and the treatment planned more carefully in advance.
The service could benefit from appropriate literature for both health and social care professionals. Written information on common interventions and care, such as fluid balance and pressure area care should be available. Care planning should be clearer and anticipatory. Laundry and continence supplies during intermediate care require further study. The necessity for turning people’s homes into a virtual hospital setting requires careful risk assessment and discussions should take place in order to support for family members needs for a home life and privacy.