Short term/ intensive response -information for design workshops

What is an short term/ intensive response? What is it? A more intensive, wrap around, intermediate health & social care response that could support a patient at home for a very short period to avoid an acute admission or facilitate discharge from hospital. A combined health, social care and voluntary sector provision that could provide very frequent calls or 24 hour carers/ sitters, for between 24 to 72 hours. For example; Carrying out observations & supporting patients to take analgesia regularly for acute pain following a fall. Intensive rehabilitation & reablement after surgery ‘Sitters’ to provide reassurance following a fall or settle back in after an admission. Support with ADLs while antibiotics for chest infection or UTI start to work. Intensive assessment in home environment over a 24-48 hr. period to inform future care package/ identify needs. Support someone to stay at home when their carer is taken ill. Capability of this service could be enhanced by integration with telehealth and telecare. Will require access to appropriate medics for review and access to an IC bed based service to step people up if needed.

National guidance/ evidence base (short term/ intensive) There is significant evidence that hospital at home and early supported discharge schemes for elderly patients with certain medical conditions can be a safe, effective and a less expensive option than hospital care and have greater levels of patient satisfaction (4). NICE guidelines for stroke, COPD and Hip fractures (5) all include recommendations based on this evidence; Telemedicine as a component of a multidisciplinary programme for heart failure has also been demonstrated to be effective in reducing admissions. (4) Data published by Public Health England (PHE) in 2015 identified twenty percent of hospital admissions among people with dementia are due to pneumonia, urinary tract infections and lower respiratory tract infections for which being in hospital is not necessary for optimal treatment. Once in hospital, people with dementia stay longer and have poorer outcomes than those without dementia. PHE suggest there is room for improvement in community services that provide early intervention for people with Dementia who have an acute condition to prevent more serious progression. (6). The National Audit of intermediate care describes a category of IC service that provides… “Assessment and short term interventions to avoid hospital admission provided to service users in their own homes. Interventions for the majority of service users will typically be short (less than 48 hours) but may last up to a week.” National Audit of IC 2015  

Who else is doing it? Examples of intensive/ short term home based response Croydon Rapid Response Service- Provides intensive nursing and therapy interventions to prevent exacerbations and in a crisis provides intensive crisis management to high intensity users. http://www.croydonhealthservices.nhs.uk/rapid-response-service.htm Barking and Dagenham, Havering and Redbridge CCGs and local councils and North East London NHS Foundation Trust- Trialling two services providing: Short-term. intensive, home-based care or rehabilitation to people experiencing health/social care crisis or to support people to return home. between one and four home visits each day – 7 days per week single point of access to intensive support/ rehab at home or a bed in community rehab unit if necessary. http://www.redbridgeccg.nhs.uk/Downloads/About-us/Improving Intermediate care Services/BHR CCGs intermediate care consultation document July 2014.pdf Nottingham Support Management and Response team (SMaRT) supports people in supported accommodation and their own homes using technology in their home to speak with an experienced support worker. The worker’s mobilse a response team if required. https://www.gov.uk/government/publications Rapid Assessment and Time Limited interventions Team (RATL) North Lincolnshire & Goole NHS Trust http://www.doncasterccg.nhs.uk/wp-content/uploads/2016/06/RATL-North-Lincs-Goole-Helen-Davies.pdf  @home service, Guys and St Thomas, London  

Who needed an intensive/ short term?   The profile of people who needed an intensive/ short term response is similar to the rapid response cohort apart from; Age-Well over three quarters were over 80 years old, slightly more than the rapid response. 49% were between 80 and 90 years old and a further 29% were aged over 90. Home situation- Slightly less live alone (64%) and slightly more already had a formal care package in place. Long term conditions- 21% had Diabetes (the highest of all responses) Mobility- more people needed supervision when mobilising (45%) than in the rapid response but less people were unable to mobilise at all (only 2%). Falls- This group had a higher risk of falls (74%) and were more likely to have a history of falls (17%) than the other home based responses. Reasons for coming into contact with services were similar to the rapid response and included falls (37%); local infection (11%) reduced mobility (6%) and social (4%) Approximately 8% of people also required some prompting or physical assistance with feeding and nutritional monitoring or assessment.

What types of interventions were needed? (short term/ intensive response) Intensive Reablement Comprehensive falls assessment Regular clinical Interventions Functional/ ADL assessment Mobility/ Transfer Assessment Medical/ clinical review Provision of equipment Increase/ new home care package Medical investigations/ tests Access to intermediate care bed if needed Review of home care package 24 hour supervision Intensive therapy/ rehabilitation 24 hour carers/very frequent calls Comprehensive Geriatric assessment Video consultations/ telehealth monitoring Review of existing homecare package Medication review/ advice Carers assessment/ carers support Telecare Joint care planning Follow up visits post discharge/ settling in Cognitive/ memory assessment Best Interests Safeguarding assessment

What types of interventions were needed? (short term/ intensive) Medical investigations included… Blood tests/ U&Es X-rays Review of mental health ECG/ ECHO Investigate cause of falls/ dizziness etc Audiology referals Clinical interventions identified were… Pain management/ relief Wound care (surgical wounds, pressure areas) Antibiotics (oral and IV) Monitoring blood sugars BP monitoring SATS monitoring Observations Catheter care Monitoring while commencing new medications IV fluids/ rehydration Bowel management Cellulitis treatment Telehealth was indicated for… Observations Access to nurses for advice (where carers are providing intensive support) Prompting Encouraging self monitoring Access to specialists for advice e.g. stroke consultant Intensive reablement included… Supported ADL practice (while recovers/ adapts to…) Practice mobility, stairs, transfers Prompting (to take meds, to eat, to maintain hip precautions, do exercises etc) Support family/ informal carers Assess need for ongoing support. Assess impact of confusion on daily living. Other types of interventions… Assessing self medication/ medication complience and setting up NOMADs Care planning for the future Practical support – including housing advice Respite @home Liaison with other services and referring on Rehabilitation included… Rehabilitation after surgery Stroke and neuro rehab Rapid access to orthortics

Who is needed to deliver them? Most frequently identified Occasionally identified Intensive Reablement Reablement workers with therapy plan Reablement workers with MH plan Reablement workers with nursing plan Comprehensive falls assessment MDT Therapists Geraitician Falls Assessor Regular clinical Interventions Nurses Nurses/ support workers Nurses/ Reablement workers Specialists Functional/ ADL assessment OTs Reablement workers ---------------- Mobility/ Transfer Assessment Physios Manual handling advisor -------------- Medical/ clinical review GPs Geriatrician Specialist Provision of equipment Reablement Officers Thaerapists --------------- Increase/ new/ review home care package Social Workers Social care staff Medical investigations/ tests Geriatricians Review of home care package 24 hour supervision Sitters (CVS) Reablement/ home care Combination of workers/ family Family Intensive therapy/ rehabilitation Physio SALT Specialist therapists 24 hour carers/ frequent calls Reablement Home care Combined carers and telecare Comprehensive Geriatric assessment Frailty Practioners ------------------- Video consultations/ telehealth monitoring ------------- ------------------ Medication review/ advice GP Pharmacy Specialist team Carers assessment/ carers support Social care CVS As appropriate Cognitive/ memory asessment/ review OPMH Psychiatrist Geriatician

What patients told us…