High Impact Change Area G: Providing intermediate care that promotes positive outcomes – case studies

Plan

Warwickshire care collaborative is one of the six national discharge frontrunners who are trialing various approaches to intermediate care. Funding has been made available from NHSE to implement these programmes. They have developed a Community Recovery Service (CRS) which went live in April 2023, with the aim of improving timely access to therapeutic intermediate care services following discharge from hospital. The main objectives of the CRS include:

• Reducing hospital length of stay and bed days lost and reducing the number of people staying in hospital who should be at home.
• Increasing the number of people receiving rehabilitation and recovery services after an acute hospital admission, hence improving patients' functional outcomes.
• Decreasing the need for long-term care and long-term care costs by reducing demand and acuity.

Implementation

The CRS model is an integrated intermediate care service, which provides up to a maximum of 6 weeks of free care (dependent on the patient’s needs and requirements) following a stay in hospital. Referrals to CRS are accepted for patients with any conditions, inclusive of those leaving hospital to their own home, who may have a new or increased care requirement, or a short-term recovery and rehabilitation need.

This service aims to commence care within 24 hours of the referral being received. The person is discharged home with four care calls to begin with, however within two hours of them returning home, an assessment is completed by the care agency to understand their individual needs to inform their care plan. Assessment is conducted within the person's home in line with the discharge to assess ethos.

All patients have access to therapy input if deemed appropriate. Therapy assessments include setting person-centred goals, which are made in collaboration with the patient. These goals are subsequently shared with the homecare providers.

Care agencies may choose to reduce the care package, with support of therapists if required and all cases can be discussed within the weekly multi-disciplinary team meetings. Continuous assessment and reduction in care can occur as appropriate through the pathway, with exit off the pathway at any time.

Outcome

Between April and October 2023:

• 4,756 packages of care were initiated via the Community Recovery Service (CRS) with an overall 5,164 referrals received.
• 53 per cent of these started within three days of referral. Work is underway to improve this further
• There has been an 80 per cent increase in the number of patients using therapy services which is in line with the CRS objectives
• 85 per cent of all referrals are accepted by therapy
• 50-70 patients per month exit CRS to independence. An average of 290 patients exit CRS each month with the majority of patients exiting to adult social care assessment
• Hospital discharge teams report a reduction in waiting times, although this is currently anecdotal. They are awaiting data to clarify this

Data sets for exits and the impact on long-term care needs are also being developed, but most patients exit the CRS with some level of long-term care which is to be expected given caseload acuity.

Patient and staff feedback is being collected. Early indications are that patients welcome the service, with people mobilising quicker and experiencing an improved quality of life.

Patient and service provider feedback:

Without the support from the carers coming in, it takes me four hours to get out of bed in the morning. With the carers it takes about 30mins and the service I am getting gives me all that life back” CRS Patient

"Having the care people come in 4 times a day at first was hard to get used to as my fall which left me in hospital made me feel confused. After a week of the carers coming in I started to feel so much better, helping me eat regularly and supporting me washing myself which I didn't like to admit I struggled to do myself. 

"After the six weeks, friends and relatives all said how much better and happier I am. The team have given me confidence to do a bit more around my flat, knowing they will be there if anything should happen".  CRS Patient

Plan

Immedicare is a joint venture between Airedale NHS Foundation Trust and Involve Visual Collaboration Ltd. The service supports care home residents and staff by providing 24/7 access to virtual clinical assessment with NHS professionals, 365 days a year.

It is a national service currently available in 655 care homes in seven integrated care systems.

Implementation

The Immedicare team of NHS nurses, paramedics, pharmacists and healthcare support workers provide professional support to care home residents and the staff that support them. This consists of clinical assessment, supervision and advice in relation to any acute issues including falls, wound care, medicines safety, end of life care and nutrition and hydration - reducing risk and providing reassurance to residents and their families.

Virtual training sessions for care home staff are provided on key topics including falls prevention, medicines administration, end of life care, behavioural challenges and supporting those with dementia.

Care home staff are encouraged to use the digital care hub to triage any clinical concerns which allows GP practice staff, community response teams and social care staff the capacity to manage issues that need to be face-to-face. Access to the Immedicare service has been shown to reduce the need for onward referral to other healthcare professionals, including those that may have resulted in an ambulance conveyance and hospital attendance.

Outcome

• 90 per cent of care home residents remain at home following an Immedicare consultation
• virtual training sessions have been accessed by over 1,000 care home staff enhancing their skills and knowledge, including in dementia care
• 25,000 care home residents have received clinical support
• 83 per cent of residents stay in the care home following a fall when supported by an Immedicare virtual assessment
• 67 per cent reduction in GP calls can be demonstrate in areas where there is positive engagement with the Immedicare service.
   

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