A POSITIVE VIEW OF INTERMEDIATE CARE FOR OLDER PEOPLE JOHN YOUNG Consultant Geriatrician Bradford Patient and service need Feasibility and effectiveness New paradigm of care

The “proper care and rehabilitation of these (elderly) patients” Warren, Lancet 1946 Elderly care medicine as the largest specialty

Living at home1.8 ( ) Reduced mortality0.65 (0.46 – 0.91) Improved physical Function 1.63 (1.0 – 2.65) Improved cognitive function 2.0 (1.13 – 3.55) Hospital Geriatric Unit v Alternative Care Odds Ratio (95% confidence limits) at 6 months Meta-analysis of 5 studies (n=1090) Stuck et al Lancet 1991

SERVICES RECEIVED BY FRAIL OLDER PEOPLE (N=821) 3 MONTHS POST-DISCHARGE CHIROPODY COM. NURSE GP HOME VISIT SOCIAL WORKER HOME CARE 47% 23% 34% 5% 44% REHAB. INPUT ??

THE EXPERIENCE OF COMMUNITY CARE Piles of unmet need Fragmented service provision Poor co-ordination of services More caring/doing, less enabling/facilitating Multiple assessments Multiple waiting lists

BASIS FOR INTERMEDIATE CARE No. 1 UNEQUIVOCAL, UNARGUABLE, UNCONTESTABLE PATIENT NEED TO TRANSFORM COMMUNITY SERVICES FOR OLDER PEOPLE

“Hospitals, Jim, but not as we know them.” Vetter, 1997

BASIS FOR INTERMEDIATE CARE No. 2 UNEQUIVOCAL, UNARGUABLE, UNCONTESTABLE SERVICE NEED TO TRANSFORM COMMUNITY SERVICES FOR OLDER PEOPLE

OUR HEALTH SERVICE IS OBSSESSED WITH BEDS ….beds ……….beds ……………beds …………………beds

“Please Sir, can I have some more beds?” “If we always do what we’ve always done, We’ll always get what we’ve always got.” Don Burwick

THE INTERDEPENDENCE OF SERVICES Young, BMJ 2001 PRIMARY CARE SECONDARY CARE SOCIAL SERVICES I.C.

WHOLE SYSTEMS THINKING Multi- agency working

BASIS FOR INTERMEDIATE CARE No. 3 NEW PARADIGM OF CARE FOR OLDER PEOPLE Whole systems working Multi-agency Person centred care Single assessment process “New ways of working” Joint budgets, staff, equipment etc.

Clear attributes of I.C. (DoH Health Service Circular 2001) Early discharge or admission avoidance Actions based on comprehensive assessment Maximises independence Time limited Multi-agency working Not pick & mix! All components needed

BASIS FOR INTERMEDIATE CARE No. 4 FEASIBILITY (Not a set of abstract concepts)

CONFIRMED EXPANSION OF I.C. TARGET 2004 BEDS +5,000 PLACES +1,700 PTS. +220,000 Capacity targets due to be met in 2004 Hansard, April, , , ,721

THE EVOLUTION OF I.C.(Needs time) EMBRYONIC SERVICE(S) DEFINED I.C. COMPONENTS WHOLE SYSTEM I.C. INTEGRATED WHOLE SYSTEM I.C. (= Multi-agency working) (=Criteria driven IC) (=Single telephone & person driven IC) (=Mainstream service) IN MATURE I.C. SERVICES (=critical mass & integrated) Favourable service level outcomes reported: - Lower DGH demand - Lower care home demand

BASIS FOR INTERMEDIATE CARE No. 5 EFFECTIVENESS (As a clinical service)

Hosp. at Home v inpatient hospital care (Cochrane review: Sheppard & Iliffe) N = 16 RCTs How many trials do you want? EXPERIMENTAL EVIDENCE FOR I.C.

SUMMARY OF HaH FINDINGS Feasible Flexible: diff. conditions diff. IC functions Clinically safe service Similar cost to in-patient care (?) Offers genuine alternative to in-patient care Increases local health service capacity Cochrane review: Sheppard & Iliffe

I.C. as a vector for whole system changes INTERMEDIATE CARE IS NOT A SCARY BUSINESS Basis for I.C.: Pressing pt & service need for change I.C. as a feasible & effective response I.C. as a paradigm shift in community care for OP i.e. to infiltrate existing services and so create an influence on attitudes, behaviour and skill- base for older people