Intermediate Care: locality integrated care

 

 

 The aim of integration is to support more people to live well at home for longer.

Maximising independence and improving the pathway from home to hospital and back is at the heart of the 2020 Vision and the National Outcomes for Health and Wellbeing.

 

    People, including those with disabilities or long term conditions or who are frail

    are able to live, as far as reasonably practicable, independently and at home or in a 

    homely setting in their community.

 

When people with a combination of physical, cognitive and functional impairments experience a flare up of their conditions they often require urgent and comprehensive assessment and support by professionals from different disciplines and agencies.

 

Many older people are currently admitted to hospital as an emergency, where they are at risk of harm from healthcare associated infection, falls, delirium and under-nutrition.  They often have a prolonged stay in hospital, higher mortality or greater risk of readmission and need for long term residential care.  Remaining in hospital once treatment is complete or being admitted prematurely to long term care are poor outcomes for individuals and for the system.

 

Maximising Recovery, Promoting Independence’’: An Intermediate Care Framework for Scotland describes intermediate care as a continuum of integrated community services for assessment, treatment, rehabilitation and support for older people and adults with long term conditions at times of transition in their health and support needs. These services offer alternatives to emergency inpatient care, support timely discharge from hospital, promote recovery and return to independence, and prevent premature admission to long-term residential care.

 

Intermediate care can be provided in:

  • Individuals’ own homes, sheltered and very sheltered housing complexes
  • Designated beds in local authority or independent provider care homes
  • Designated beds in community hospitals

 

Intermediate care provides safe, effective and person centred care that delivers good outcomes for people and improves flow through acute hospitals.

 

Partnerships with comprehensive intermediate care services are showing greater reductions in rates of emergency bed days and delayed discharge compared to those which have been slower to implement integrated intermediate care. Some partnerships are simplifying access to local Intermediate Care services by creating a locality hub or single point of access.

 

JIT has established a Community of Practice to connect Intermediate Care practitioners and managers to spread and scale up the adoption of Intermediate Care across Scotland.

 

This document describes the range of intermediate care services provided across Scotland at May 2015. It provides contact details to encourage shared learning as integration authorities continue to enhance their intermediate care arrangements.