Intermediate Care

What is intermediate care?

Intermediate care delivers a short burst of extra care and rehabilitation outside hospital to help people recover and regain their independence as quickly as possible.

It can provide support in many situations, such as: when an older person has an illness like a water or chest infection that can easily be treated at home rather than hospital;  when an existing health condition worsens; when an older person has fallen and lost their confidence;  if someone is weak and needs help to settle back home following a hospital stay or if their carer is unwell and not able to look after them.

The official definition of intermediate care is:

A range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission and premature admission to long-term residential care, support timely discharge from hospital and maximise independent living. Intermediate care services are usually time limited, normally no longer than six weeks and frequently as little as one or two weeks. Intermediate care should be available to adults age 18 or over‘.

National audit of Intermediate Care 2017 NHS Benchmarking (Plain English approved definition)

Intermediate care services in Doncaster

A list of current intermediate care services in Doncaster can be found here

Details on how to refer to the service will be available shortly.

What are we doing to develop intermediate care services?

We recently conducted an in-depth review into the needs of Doncaster residents and the role of intermediate care services in meeting these needs. The Intermediate Care Project Team spent time talking to patients and those involved with their care. With partners from a range of health and social care organisations they also conducted detailed reviews of the care pathways of 30 patients, assessed the records of over 1,000 people and asked panels of local experts to identify what services need to offer in the future to best meet the needs of the borough’s population.

The Case for Change:

The review identified that;

  • Our current services are too complicated and difficult to navigate
  • Services are not as coordinated as they could be
  • Current services aren’t personalised to the individual
  • There needs to be emphasis on proactive services, helping residents keep their independence at home
  • People tend to recover more quickly in their own home and social connections are an essential part of that process
  • Challenges in the future will mean the whole workforce will have to work differently in supporting people living with dementia and cognitive impairment

You can read more detail about our case for change here

Joining up intermediate care services.

NHS Doncaster CCG and Adult Social Care in Doncaster Metropolitan Borough Council are working together to develop intermediate care services further so:

  • there’s more of this type of support in the community;
  • services can be easily accessed when people need them;
  • services are equipped to meet the needs of an increasingly ageing local population; and
  • support is organised in a way that makes it easier for teams to work together and co-ordinate care around the needs of an individual.

By doing this we hope to:

  • help reduce the time people need to spend in hospital or bed-based services
  • provide more assessment and support closer to home
  • enable more people to stay independent at home for longer
  • make sure we are using the resources we have in the most effective way

This short film explains why joining up care in this way is so important

 

Testing a new way of working

Over the coming months we will be working with partners to test some of these new ways of working.

Rapid Response 

One of the first examples of integrating intermediate care services in Doncaster includes reducing hospital admission through better working together.

The rapid response is an inter-agency, multi-disciplinary response which went live on the 23 January,  2017. It’s initial focus was on falls and referrals made by Yorkshire Ambulance Service, but is already taking referrals from GPs to provide a short burst of extra support in a variety of circumstances. Early evidence suggests it is helping people to stay at home.

You can read a case study about Joan’s story here

You can also watch a short video below of Jayne Partingdon, Clinical Lead for the Rapid Response Team at Rotherham, Doncaster and South Humber NHS Foundation Trust and a patient on how the Rapid Response service has supported her to keep her independence at home.

Hear from Ann Quickfall, a patient who received treatment from the Rapid Response service (June 2019):

Integrating Health and Social Care Rehabilitation and Reablement Teams

We are planning to launch a new, integrated health and social care rehabilitation and reablement service in September 2017.

This will bring together two existing teams STEPS (Short Term Enablement Programme) provided by DMBC and CICT (Community Intermediate Care Team) provided by RDaSH as one service.

By working together the aim is to offer a more co-ordinated service with a greater range of support to meet both health and social care needs.

CONNECTED

Our newsletter ‘Connected’ is available here:

Connected Newsletter Issue 7

Connected Newsletter Issue 6

Connected Newsletter Issue 5

Connected Newsletter Issue 4
Connected Newsletter Issue 3
Connected Newsletter Issue 2
Connected Newsletter Issue 1

Further documents relating to this work are also available here

Project Team contact details:

Paul.Burton@nhs.net

Claire.warren7@nhs.net