Intermediate care including reablement

Why this is important

Recommendation 1.5.3 states that for bed-based intermediate care, the service should start within 2 days of a referral being received. There is moderate-quality evidence to suggest that if the referral is made from acute care then the person's condition will begin to deteriorate if intermediate care does not start within 2 days. There is no clear evidence about the most effective timescale for people whose referral is being made in different circumstances, for example if they are at home and being referred for home-based intermediate care or reablement to prevent hospital admission or improve independence.

A comparative evaluation is needed to assess outcomes associated with different lengths of time between referral and starting the 4 intermediate care service models. Also, to assess the resource impact and overall cost effectiveness of different waiting times. Effectiveness and cost-effectiveness research should be complemented by qualitative data from people receiving and delivering the service to investigate their views and experiences and the perceived impact on the person's level of independence and quality of life. 

Why this is important

The skill mix and competency of a home-based intermediate care team can influence the quality of care and outcomes. The evidence on views and experiences of home-based intermediate care is exclusively from health and social care practitioners, with no evidence from other care and support practitioners from the community.

Comparative studies are needed to determine the effectiveness and cost effectiveness of different approaches to delivering home-based care and support, in terms of team skills, structure and composition. A better understanding of how these factors influence quality of care could improve outcomes for people who use home-based intermediate care.

Qualitative studies are also needed to explore the views and experiences of a wider range of care and support practitioners. This will help practitioners learn about and understand each other's roles, which will improve their delivery and quality of care.

Why this is important

There is no evidence on the effectiveness and cost effectiveness of crisis response services. The evidence that is available shows that practitioners and people using this service found the short-term support provided (up to 48 hours) too limited to address the needs of older people. It is also unclear if health and social care practitioners fully understand the purpose of the crisis response service when making referrals.

Comparative studies are needed to evaluate the different approaches to structuring the delivery of crisis response services to improve outcomes.

Cost information is also needed. This needs to be supplemented by qualitative data to explore how well the crisis response service is understood among practitioners.

Why this is important

Some intermediate care and reablement services support people living with dementia. However, others specifically exclude people with a dementia diagnosis, because they are perceived as being unlikely to benefit. There is limited evidence on the effectiveness and cost effectiveness of using intermediate care and reablement to support people with dementia.

There is no evidence on the views and experiences of people living with dementia, their family and carers, or health, social care and housing practitioners, in relation to the support they receive from intermediate care and reablement services.

Comparative effectiveness and cost-effectiveness studies are needed to evaluate the different approaches to delivering support to people with dementia. This will help to ensure that both a person's specialist dementia needs and their intermediate care and reablement needs are accommodated in the most effective way. The studies should include a comparison of care provided by a specialist dementia team with that provided by a generalist team; and access versus no access to memory services. These need to be supplemented with qualitative studies that report the views and experiences of people living with dementia, their family and carers, and practitioners.

Why this is important

The evidence that reablement is more effective than home care at improving people's outcomes is based on data from 1 period of reablement. In current practice, people can use reablement repeatedly. There is no evidence on the outcomes and costs for people who use reablement more than once.

In addition, there is no peer-reviewed study that measures the impact of different durations of reablement for different population groups. This is important because in practice, reablement is funded for up to 6 weeks only. However, some people are offered reablement for a period of more than 6 weeks based on their identified needs. At present there is very limited knowledge about the costs and outcomes of reablement as provided to different population groups, and the optimal duration for these groups.

Longitudinal studies of a naturalistic design with a control group are needed to follow up people who have received reablement several times or over a longer period than 6 weeks, or both.

Comparative studies are also needed to understand the long-term impact of duration on costs and patient outcomes, by comparing 6‑week reablement services with services that last longer than 6 weeks.

Why this is important

There is evidence that poor integration between health and social care is a barrier to successfully implementing intermediate care. A management structure that has a single point of access can help to improve communication between teams and speed up referral and access to services.

Comparative studies are needed to evaluate the effectiveness and cost effectiveness of introducing a management structure that has a single point of access versus a structure with no single point of access. This will help to reduce the length of time from referral to receipt of intermediate care.

Why this is important

There is some evidence that people who used home-based intermediate care found their care ended too suddenly at 6 weeks, and poor communication compounded this negative perception. The optimal time limit can differ depending on people's health and care and support needs.

Studies of comparative designs are needed to assess the effectiveness and cost effectiveness of different intensities and durations of home-based intermediate care for people with a range of care needs.

Why this is important

Addressing the cultural, language and religious needs of black and minority ethnic groups can remove some of the barriers to accessing support services. There is no evidence on the effectiveness and cost effectiveness of intermediate care in supporting people from black or minority ethnic groups to access intermediate care and reablement.

Comparative effectiveness and cost-effectiveness studies are needed to evaluate 'what works' in terms of planning and delivering intermediate care for minority groups. This includes all 4 service models of intermediate care. Qualitative data are needed on the views and experiences of people from black and minority ethnic groups, their family, carers, practitioners and voluntary support groups to inform the development of a service that meets the needs of this population.