Guidance

Context

Context

The NHS and social care sectors are experiencing unprecedented pressure due to increasing demand from people living longer, often with complex needs or impairments and 1 or more long-term conditions. Admission to hospital and delays in hospital discharge can create significant anxiety, physical and psychological deterioration, and increased dependence. Multidisciplinary services that focus on rehabilitation and enablement can support people and their families to recover, regain independence, and return or remain at home.

Intermediate care uses a range of service models to help people be as independent as possible. It can prevent hospital admissions, facilitate an earlier, smoother discharge, or be an alternative to residential care. It can also offer people living at home who experience difficulties with daily activities a means to maintain their independence.

This guideline focuses on the 4 service models included in the NHS Benchmarking Network's National Audit of Intermediate Care summary report 2014:

  • bed-based intermediate care

  • home-based intermediate care

  • crisis response

  • reablement.

These services are for adults aged 18 years or over and are delivered in a range of settings, such as:

  • community settings, including:

    • people's own homes

    • temporary accommodation

    • specialist housing, such as sheltered, warden-supported or extra care housing

    • supported living housing (including shared lives schemes)

    • day centres

  • residential and nursing care homes

  • dedicated intermediate care and reablement facilities

  • acute, community and day hospitals

  • prisons.

The concept of intermediate care was developed in 2000 in the Department of Health's NHS Plan and implemented in England through their National Service Framework for Older People. Reablement specifically received policy support in 2010 when it was recognised as a means of prolonging or regaining independence.

The Department of Health and Social Care's Care and Support White Paper subsequently announced the transfer of funds from the NHS Commissioning Board to local councils in 2013–14. Most recently, NHS commissioners and local authorities have been required, via the government's Better Care Fund and the NHS Five Year Forward View, to take a more integrated approach to planning by pooling budgets to support models of integrated care and support, including reablement and intermediate care. The Care Act 2014 requires that services, including intermediate care, should consider how person-centred support is planned to promote individual wellbeing.

This guideline covers intermediate care services provided by the NHS and social care, and how these are best planned and delivered alongside services provided by the voluntary and independent sector. It identifies the key components of the intermediate care pathway (see below), and how services can work together with the person and their support networks to deliver effective intermediate care. The guideline draws on the evidence base to highlight best practice, making recommendations that aim to provide equity of access and a more integrated approach to provision. It also aims to bring greater coherence, parity and responsiveness to service delivery, reducing duplication of effort and clarifying responsibilities for service providers.

The intermediate care pathway

Local areas may take different approaches to configuring their intermediate care service depending on existing resources and team structures, but the pathway should always include the following functions (described in more detail in the recommendations):

  • Assessing the need for intermediate care – this includes gathering information about the person and deciding which intermediate care setting is most appropriate. If the person is in hospital, their assessment may include developing goals to include in the referral to the intermediate care team. If the person is at home the assessment may be completed by a social worker, community nurse, crisis response team, or community social care occupational therapist.

  • Acceptance by the intermediate care service – an individual plan is then developed by the intermediate care team, based on the person's assessment. Goals are agreed with the person and then reviewed regularly. The plan should contain enough information so that staff visiting the person and providing their rehabilitation know what needs to be done.

  • Delivery of the service – this should always be based on the agreed plan, and if problems arise then support staff should be able to contact the assessing practitioner in the intermediate care team.

  • A formal review – this should be undertaken as the person approaches achieving their goals with a clear plan for transition from the intermediate care service. If the person has ongoing support needs there may be a handover to a new home care provider or day service. If the person has achieved their desired level of independence the plan may include information about how to refer themselves back into the service if they need to, and links to community services that can support them.