Transforming Intermediate Care

The HMR Intermediate Tier Service (ITS) was the result of the coming together of a number of partners responsible for the care and treatment of residents within the HMR locality including the Acute Trust, GP Federation, the local Borough Council and adult social care, BARDOC (the local out of hours provider), and the local clinical commissioning group (CCG).

In 2014, changes to commissioning meant an outcomes framework was adopted with a lead provider (Pennine Acute Hospital Trust) which was jointly commissioned by Heywood, Middleton and Rochdale CCG and Local Authority.  The aims of this project were:

1) Collaboration, integration, and the coordinating of care delivery across providers;

2) Innovative ways to deliver more out of hospital care through health and social care integration; and

3) Focus on ill health prevention and admission avoidance.

The key objectives were:

• Reducing length of stay in intermediate care and rapid response teams from 6 weeks to maximum 2 weeks
• Expanding bed capacity for the residents of HMR through the use of virtual and intermediate care beds
• Creation of a GP-led service with a focus on rehabilitation and re-enablement

As part of this collaboration, a group was formed to explore what could be done differently to support older residents who were experiencing short stays in hospital. Did they really need an inpatient stay or could their needs be met in a more appropriate environment?

The group undertook an audit of 100 sets of case notes which were selected at random. All had the commonalities of being a patient aged 65+ who had experienced a 0-2 day non-elective (emergency) admission to hospital.

The outcome of this audit found that 58% of those patients could have potentially been cared for in an alternate setting, namely a more robust Intermediate Care Service.

Changes to commissioning meant an outcomes framework was adopted with a lead provider (PAHT) which was jointly commissioned by the CCG and local authority. This brought about collaboration, integration, and the coordinating of care delivery across providers, where innovative ways to deliver more out of hospital care were developed, focusing on ill health prevention and admission avoidance.

This integrated approach to service development was quite transformational at the time, and still is. The Rochdale Intermediate Tier Service model that was created took the best that each of the partners could offer under one umbrella. Whilst rapid response teams, community rehabilitation beds or enhanced bed with nursing and medical support had been tried and tested time over in many areas, none, that I was aware of, were supported by the local Borough Council and adult social care which were able to rapidly mobilise the right care for patients, in the right place, at the right time, with an acute hospital providing rapid access to diagnostics all within one service offer.

What this meant in real terms was a setup radically different from a traditional hospital ward and instead focusing solely on rehabilitation and enhancing independence and future quality of life. This ranged from simple activities of living such as encouraging patients to eat their meals in the dining room as opposed to remaining in their beds, which enhanced social interactions not only with staff but also with other patients, sharing their experiences, making friends and increasing overall confidence. Encouraging patients to manage their own medications also supports independence and was a move away from the historic practices which created dependence.

From a work point of view this meant regular and comprehensive MDT meetings where all elements of a patient’s life and needs were explored including looking at de-prescribing, at functional improvements and even advanced care planning where appropriate.  The cost of running the service with 48 community beds, Rapid Response Team and associated virtual beds on an annual basis is circa £3,986,485.

Our approach to designing this service model demonstrates how recommendations in section 1.5 and 1.6 of NICE guidance NG74 can be used to design and implement a frontline intermediate care service.

We achieved a reduction in length of stays from an average of 35 days to 11 -14 days, and this is achieved with a marginal percentage of re-admissions. Our Urgent Community Care Team now sees each month an average of 140 new referrals, 100% of which triaged, and contact made either face to face or by telephone within 2 hours.

Over 90% of our patients are then managed in the community either in their own homes or in one of our two intermediate care facilities.

Our work has been acknowledged from a training point of view as shown by being shortlisted for a national award in the Student Nursing Times 2019 Awards and won ‘Best Event’ in the national End PJ Paralysis Awards.

Some areas of future focus are defining the competencies of intermediate care for all healthcare professionals and engaging in the National Intermediate Care benchmarking audit. We are also looking at how can we break down barriers that create health inequalities.

COVID-19 has created a new set of challenges. This has been particularly difficult for re-enablement work in promoting activity while also minimising the risk of infection. Our staff faced real challenges with trainees seeing more of their patients die in the space of three weeks than the previous six months, staff suffered sickness, lost loved ones, saw teams fragment and worked through redeployments whilst maintaining our ethos of working collaboratively.

As the lead GP specialising in intermediate care work for the service, and one who at the time was only a few years post CCT, certain memories stand out.

One was how working across multiple teams required a different set of skills. It was the first time I would hear about the idea of ‘system leaders’, people working across organisation’s and breaking down hierarchies.

One was the power of honest conversations with patients about over-medicalisation, over-diagnosis and the dangers of over-treatment.

I also remember acts that were simple for us to deliver but had a profound impact on our patients, such as the dying lady who we helped to see the local lake one last time before she passed away, or the elderly patient deemed immobile and being hoisted as a hospital inpatient following years of social isolation, but actually went home walking with a bit of help and patience.

Secondly, the man who was repeatedly investigated for low blood pressure in hospital only for me to find his home littered with stockpiled medicines which he never took.

Thirdly, it would be talking about how we were “Transforming Intermediate Care” at the 2016 Royal College of General Practitioners Conference.

Finally, more recently was the resilience of the human spirit as staff cared for a 100-year old patient who was alive during the Spanish flu pandemic and we rehabilitated through another pandemic today.

Looking to the future, there is still much we can do and we are always looking to improve our services; trying different triage tools, looking at collaboration with the new PCN’s, defining the competencies of intermediate care for all healthcare professionals and engaging in the National Intermediate Care benchmarking audit, and looking at how can we break down barriers creating health inequalities.

For further information please contact:

Ruth Chamberlain, Directorate Manager ITS & Urgent Care; Ruth.Chamberlain@pat.nhs.uk

Jacqueline Heatley, Assistant Director of Nursing Urgent and ITS Directorate; Jacqueline.Heatley@pat.nhs.uk