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Intermediate Care in practice: some themes from England

Intermediate Care in practice: some themes from England. Nye Harries CSIP Older People’s Programme Department of Health. CSIP Older People’s Programme. Task force on delayed discharges in 2002 Now cover range of older people’s agenda Whole system focus Critical friend role

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Intermediate Care in practice: some themes from England

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  1. Intermediate Care in practice: some themes from England Nye Harries CSIP Older People’s Programme Department of Health

  2. CSIP Older People’s Programme • Task force on delayed discharges in 2002 • Now cover range of older people’s agenda • Whole system focus • Critical friend role • National policy input

  3. What do we mean by intermediate care? • Multi-agency working • Comprehensive shared assessments • Person-centred care based on enabling/rehabilitation approach • Short-term interventions to maximise independence, based on key outcomes

  4. England: recent policy context Ian Philp’s key messages: • Early intervention & assessment of old age conditions • Community management of long-term conditions • Early supported discharge whenever possible

  5. National indicator on Intermediate Care • “Achieving independence for older people through rehabilitation/intermediate care” • Joint indicator & all communities will report • Looks at % of +65s receiving IC/rehab at home 3 months after discharge • Also delayed discharge & emergency bed days indicators

  6. But the wider world is changing…. • Case finding/case management, community matron roles & development of specialist nursing teams • The growing awareness about older peoples’ mental health issues, including dementia • Growing interest in performance review of community services, including IC • The self-directed support agenda of IBs and DPs

  7. Intermediate care: the pitfalls • Silo working & “criteria-itis” • Managing the boundaries • Evaluation & outcomes

  8. Why evaluate intermediate care? Requirement of HSC 2001/1: LAC (2001) To demonstrate outcomes of service/system changes For performance monitoring Potential to create a continuous quality improvement process

  9. When to evaluate? Ideally before starting a new service or making changes to current practice Identify measures/benchmarks against which to test changes (or use 1st evaluation to set the baseline)

  10. Who to involve? People on whom change or performance will impact Include stakeholders 2 levels up- or down-system from the service being evaluated

  11. Evaluation Framework based on the Balanced Score Card Methodology Examples of theRange of tools/ methods to evaluate USER SATISFACTIONOUTCOMES PROCESS/ TOOLS COST EFFECTIVENESS - quality of life measures- satisfaction surveys- complaints - goal achievement- reduction in delayed discharges Dimension to Monitor TOPIC - training programmes- referral rates- skill mix- interface management - LoS in acute beds- reduction in care packages Source: Developing intermediate care - a guide for health & social care professionals. King’s Fund, 2002

  12. User satisfaction • Patient/user/carer questionnaires • Quality of life measures: • SF36* • EQ-5D • PDQ 39 (specific to Parkinson’s disease) • COPE (carers’ satisfaction) • Achievement of jointly agreed personal goals: • Canadian Occupational Performance Measure* • TELER (Treatment and Evaluation of Le Roy Scale)* • Goal Attainment (Achievement) Scale* • Complaints • Care outcomes • Goal achievement scales • Assessment tools/outcome measures: • Barthel Index • Abbreviated Mental Test Score • HONOS • Cape (Clifton Assessment Procedures for the Elderly) • Carer Strain Index • Elderly Mobility Scale • Assessment and Motor Performance Scale • FIM (Functional Independence Measure) • FAM (Functional Assessment Measure) • GDS (Geriatric Depression Scale) • Hospital Anxiety and Depression Scale • IADL (Index of Independence in Activities of Daily Living) • Nottingham Extended ADL Scale • REPDS (Revised Elderly Persons Disability Scale) • Rivermead Mobility Index • TOMS (Therapy Outcome Measure Scale) • Waterlow Assessment • Theories of Change • Reduction in delayed transfers+ • Inappropriate admissions+ • Inappropriate re-admissions+ • Admission rates to long-term institutional care+ • Premature admissions to long-term care+ • Reduction in community care packages to individuals+ • Processes • Clear criteria for admission to intermediate care services/settings • Care planning includes personal goal setting • Information/publicity to enable appropriate referrals • Referral rates/ routes • Staffing levels/ skill-mix • Training programmes e.g. • Rehabilitation approach/focus • Risk management in the community • Ethnic issues • Team development • Early case-finding and proactive case management • Single point of access • System for sharing client information across the care system (link to single assessment process) • Clear arrangements for managing Interfaces between services/ settings • Critical incident techniques • Cost-effectiveness • (Few examples of measures available; few agreed benchmarks) • Length of stay in all intermediate care settings • In general • By specific diagnosis/ other categories • Length of stay in acute beds • Intermediate care clients • Other specified groups • Decrease in inappropriate emergency admissions • Reduction in delayed transfers • Prevention/health promotion e.g. by early case-finding • Management of chronic care at home Examples of four topic areas and a range of tools/measures that can be used to evaluate intermediate care (please note this is not an exhaustive list) King’s Fund 2002 Key: * Can also be categorised in Care outcomes + Can also be categorised in Cost-effectiveness

  13. · Admission to long-term care · Acute readmission rates · Standard scoring · Patient feedback – systems e.g. Barthel · confidence, motivation, Patient/professional goal push/pull behaviours attainment · · Timely admission Length of stay · · Timely discharge Reason for admission · Admission/referral source · Discharge destination · · Appropriateness of referrals Capacity occupancy · Timely response to referrals · · Over 65 emergency Sitrep discharge delays · admissions (acute) Over 65 length of stay (acute) · 1. User/staff satisfaction 2. Care outcomes Organisational level Team/unit/system level Patient level 3. Processes 4. Resources Source: Lambeth PCT, part of ‘Pursuing Perfection’ initiative

  14. Setting up an evaluation system • Agree service to be evaluated & timeframe • Identify stakeholders & involve them • Select & prioritise dimensions to evaluate • Select a range of measurement tools • Review analysis procedures • Decide reporting procedures • Agree change mechanisms to deal with findings

  15. Early intervention framework HIGHLY COMPLEX USERS, MANY OF WHOM WILL BE ADMITTED TO HOSPITAL MORE THAN ONCE Timely discharge CASE MANAGEMENT Institutional avoidance SUBSTANTIAL RISK Community services SPECIALIST DISEASE MANAGEMENT INVOLVE-MENT Enablement LOW TO MODERATE RISK Early intervention Simple services SUPPORTED CARE AND SELF CARE Lifestyle LITTLE IF ANY RISK GENERAL POPULATION Information Citizenship

  16. The future: Intermediate Care …..in a preventative framework …..as a focus on outcomes …...operating as an integrated service

  17. Thank you nye.harries@dh.gsi.gov.uk www.changeagentteam.org.uk

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