Yvonne McWeanLambeth Primary Care Trust

24th February 2009

ObjectivesTo introduce the Strategic Vision for

Intermediate CareTo understand the definition of intermediate careTo understand the drivers for changeTo gain an understanding of the local pictureTo look at the opportunities for a new model of

intermediate careTo understand can benefit from intermediate

careTo understand why we need user involvement

Strategic Vision for Intermediate Care Services in LambethDeveloped jointly with LBL ACSSets out direction and vision for continued

development and provision of intermediate care in Lambeth over the next 3 years

Local services have developed and while they have progressed in some areas there are still a number of gaps

Need to deliver in a more integrated and effective way with the local authority and others

Defining Intermediate CareIntermediate care is a range of needs-led,

transitional and integrated services that are intended to maximize health gain and:to prevent unnecessary admission to an acute

hospital;to facilitate timely discharges from acute

hospital;to reduce the use of avoidable institutional

care; andto support optimal independent living.

Other criteria:Other criteria often included are that input: -

is time limited, usually lasting no longer than six weeks

is provided on the basis of a comprehensive assessment, a structured care plan and goals that involve active therapy, treatment and an opportunity for recovery;

involve multi-professional working, within a single assessment framework

National and Local DriversWide range of drivers:

Nationally – NSF’s, Our health, our care, our say, development of case management models, National Stroke Strategy (early supported discharge), delivery of waiting list targets

Locally – Joint OP strategy, management of people with LTCs, Lambeth’s Commissioning Strategy Plan and Healthcare for London – moving more care closer to home, Stroke Modernisation Initiative, LBL Sheltered Housing Review

Current provision Lambeth Community Care and Pulross Intermediate Care Centres

– two 20-bedded units providing a range of services Supported Discharge/Rapid Response Team – capacity 50 patients

cared for in their own homes Investment of nearly £3 million – PCT funded and provided

(2006/07 figures) Over £200k invested in inpatient services for 2007/08 Service utilisation (ref cost 2006/07)

Inpatient 69% SD/RRT average number of contacts per day 66 Approx 20% of SD/RRT referrals are declined Costs – 28 day admission varies from £5.7k - £7k depending on costs

used SDT – 28 days £1.9k- £3.4K depending on costs and level of care

package (pg20)

Local picture - StatsOver 65’s account for 23,540 (8.75% of the

population) – compares to 11.8% for LondonNo big increase in overall numbers expected –

25,389 by 2010.Average age – 80 years with the over 65’s

accounting for 86% of our patients80% of our referrals come from hospitalsReasons for admission - falls, post-acute illness,

post-operative rehab Average length of stay – 27 days72% of patients are discharged back to their own

home from an IC bed

ConclusionsNo access to services 24/7Community services are running above capacity – inpatients below Service provision has predominantly concentrated on supporting

hospital discharge – (in line with national picture and evidence base)

Perception of staff regarding increased acuity of patient condition – especially those admitted to inpatient units

↓ number of people with stroke and heart failure admitted to inpatient units since development of community services – HF nurses, ESD team for stroke

Low referral rate from primary care and LAS40% of people on SDT caseload also in receipt of social care

packageMany people who would benefit from intermediate care

interventions are declined service as they are identified as having no rehabilitation need

Work streamsThe project board identified key work

streams :Community servicesBed based servicesAccessing servicesInformation technologyCase findingUser involvement

Opportunities for the new model of intermediate care• Providing a more community orientated model with

rehabilitation closer to and wherever possible in the patients own home

• A partnership model with joint services from health and social care

• Providing services for more people• Proactive long term condition management• A comprehensive and responsive service capable of

flexing to meet patient need• Person-centred approach• Consistency and equity of access• Developing extra care housing• Utilising assistive technology

Person Centred

Nursing care

Components of Community Intermediate Care Services

Rehabilitation Re-enablement

Therapy services

Social care

Medical support

Rapid response

Medicines management

GP services

Extra-care housing

Community mental health

service

Older people’s services

Voluntary service

Stroke pathway

Equipment Provision

Psychological services

Assistive technology

Long term conditions

management

Falls pathway

Day hospitals

Who can use intermediate care?AdultsResidents of LambethPeople who are medically stablePeople who demonstrate the potential to

benefit from time limited rehabilitationPeople who require multi-disciplinary

intervention

And either:are experiencing an acute health problem (e.g. fall,

infection) from which they are expected to recover or greatly benefit from a short period of support to facilitate recovery thereby preventing an unnecessary hospital admission, or

require further active rehabilitation to facilitate discharge from hospital following an episode of illness or injury, or

have complex problems which would benefit from a co-ordinated rehabilitation package, or

require further assessment and a period of recuperation before commencing a rehabilitation programme, or

require a period of recovery to enable recuperation from illness or injury before assessment regarding their long term placement needs, or

require intervention and support as part of the planned management of a long term condition.

User involvementUnderstand experiences of previous service

usersUnderstand the expectations of future service

usersInform future decision making about

intermediate care

Exercise – who can benefit from intermediate careA patient who has had a knee replacement?A patient with COPD who has suffered several

exacerbations that have reduced their functional independence?

A patient who requires only SLT following their stroke?

A patient with a complex brain injury who will need specialist long term rehabilitation?

A patient who has had a fall and gets easily confused due to their dementia?

A patient with an unexplained high fever, fatigue and confusion?

Any Questions?