THE ROLE OF INTERMEDIATE CARE IN DELIVERING IMPROVED OUTCOMES FOR OLDER PEOPLE Seminar Presentation November 2015 By Professor John Bolton (Institute of Public Care – Oxford Brookes University)

*The evidence for Prevention Universal Help – the Public Health Agenda Focus on keeping well and active Focus on keeping people out of the formal care system Short Term help for those in crisis Focus on outcomes from short interventions e.g. equipment including assistive technology Targeted help for those with eligible needs Focus on: Recovery model in mental health; reablement for older people; progression for adults with Learning Disabilities. Targeted help for those with long term conditions Helping people live with dementia Helping people live with long term conditions Low level services can accelerate a persons need for more care

New Model of Social Care – Getting the right intervention at the right time Diverts some people away from formal care solutions by offering the right equipment including telecare or family or community solutions – OT critical part of this (North Tyneside/Shropshire) Helps people in a crisis but focuses on their rehabilitation and recovery so that they need less formal longer term care –Nurses, OT and Physios Critical part of this – getting the right Intermediate Care (Torbay) Helps people live better with longer term conditions including dementia care - strong link to skills of multi-disciplinary team (MDT)

My evidence About one third of the admissions of older people to residential care can be avoided if the right set of interventions are available and offered to them at a time of crisis. Don’t assess during the crisis – hold the person with health and care resources (preferably at home) and then assess after a period of six to twelve weeks. Reablement and Recovery are a really important part of the post hospital care – either self managed (supported by a therapist) or managed with additional help – e.g. domiciliary care reablement. This should happen at home but may happen in a residential care establishment set up for that purpose.

The first problem Do too many older people end up in residential care after an episode in an acute hospital? Numbers of older people entering state funded residential care has been decreasing (about 3% per annum) for over a decade

Case example from Vale of Glamorgan in 2011 Health Board urged the local authority to help them in speeding-up hospital discharges

But the outcome was more cost to both health and social care

Study by Newton (Europe) in 5 Health and Care Communities Common findings from 5 different places: Missed opportunities in community to avoid hospital admissions – e.g. falls prevention Missed opportunities for discharge home Overstated needs for older people requiring discharge support – includes overuse of reablement for those who might manage their own recovery Many professionals don’t know what is available – often offer simplistic solutions including domiciliary care or residential care Those delivering front line care need a different skill mix to maximise efficiency and effectiveness

Is health and social care integration the answer? Linking the same old approaches to health and social care together in a new system delivers poor outcomes for older people and is financially unsustainable – evidence from England – Solihull, Peterborough, Knowsley, Wiltshire, Barking and Dagenham and others A current study in England (unpublished) into patients going through acute hospitals suggests that 20% of admissions were avoidable(mostly with improved community health care) and 75% of the assessments of older people’s (in the hospital) overstated their needs from what was required – combination of: ignorance of what is available; caution in assessment and assessment at the wrong time (before recovery) – includes 30% of avoidable residential care admissions

Integrated services are the solution when: All parties agree on the longer term outcomes from the health and care system An acceptance that continuing to run the current system as is will not get better outcomes – there needs to be change There is a strong investment in community health services (GPs, therapists and nurses) that support those objectives The system focusses on recovery and recuperation of older people “Interventions” are clearly measured for the outcomes they attain – not a focus on “assessments” Services are commissioned for the outcomes they deliver and all providers are held to account for these

Getting the interventions right – Residential Intermediate Care If a person is discharged from hospital to an intermediate care bed where the focus is on helping a person recover and get better there is an 80% chance they will return home If a person is discharged from hospital to a residential care bed awaiting further assessment – there is an 80% chance the person will remain in that residential care setting It was not the assessment that mattered but the interventions that are on offer!

Key objectives for Intermediate Care Focus on the opportunities for recovery and recuperation – different for each individual Has to be an integrated offer between NHS and Social Care Staff Significant role for Therapists – best to develop assessment and right interventions (Community Therapists know best – and better to recover at home) Strong focus on pushing people towards recovery (against their wishes sometimes?) Performance Indicators post hospital discharge must focus on: 66% need no more care after short term help 80% of those in a bedded facility should return home Outcomes from Intermediate Care may be poor risk averse assessments rather than poor intermediate care

Intermediate Care is not ONE service but a range of interventions on offer to help: Those older people for whom there is a chance of recovery e.g. therapists and reablement domiciliary care – don’t give up on people too early! Those older people who have multiple long term conditions – ensure everyone (especially the patient and their carers) knows how best to help the person manage their long term condition Help people to live with a condition and use the technology available to assist them – e.g. Living with Dementia; Offer appropriate palliative care for those who are known to have terminal conditions

You will know that your Intermediate Care Services are working when: You find that there is a smooth and clear pathway from hospital to the community and delayed discharges are not an issue Delayed discharge is seen as an issue for community health and social care working in partnership The numbers of older people being admitted to residential care are falling or where they have already reduced are stable The numbers of re-admissions begin to reduce Each person has a clear health and care plan which focuses on recovery and managing their long-term conditions – this is supported by all providers of health and care