1. Single point of access and rapid response- information for design

2. Why a single point of access?
Currently at least 6 ways to access intermediate care…

3. What is a rapid or urgent response?
Two parts:
Rapid access to an integrated health & social care assessment in the home environment, directly from the community
In-reach into A&E, MAU, acute wards and other bed based services to assess health and social care needs and facilitate discharge.
Currently this type of rapid assessment only available once someone has accessed acute services e.g. RAPT, IDT, STEPS via SPOC. In the future needs to be accessible directly from the community to avoid A&E attendances and admissions.
Key points from review;
This response would assess and develop a care/ support plan to meet the immediate health and social care needs of a person and facilitate access to appropriate support/ services to deliver that plan.
It would need to have rapid access to home based reablement support and/ or increased home-care.
Single point for assessment and access to IC services (bed and home based)
Could also include a crisis falls response.

4. Evidence Base for rapid response

5. National guidance
NHS England suggest that frail, older people should have access to rapid support close to home in crisis. Their guidance, on developing pathways for frail older people, cites work by the Kings Fund (2013) and the silver book (2012) recommending 8 interventions that should be available as part of a rapid response;
Single point of access.
Comprehensive Geriatric Assessment
Ambulatory emergency pathways with access to multi disciplinary teams within four hours.
Mental health assessments as appropriate
Access to a community Geriatrician for expert clinical opinion, clinical support and supervision.
Rapid access to ambulatory clinics available in acute trusts and community settings.
Personalised care plans including emergency contingency plan, advanced care plan and EOL plans.
Shared care protocols with ambulance services to enable older people to stay at home.
NHS England February 2014
Services that are able to respond quickly in a crisis play a major role in reducing admissions to secondary care and maintaining people at home. Admission avoidance is a key function of intermediate care services. 
National Audit of IC 2015

6. Who else is doing it? Birmingham Rapid Response Service
London Rapid Response Service 
Croydon Rapid Response Service   
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Rapid Assessment and Time Limited interventions Team (RATL) North Lincolnshire & Goole NHS Trust
iCares Sandwell  

7. Who needed a rapid/ urgent response?
Gender: Female 59% Male 40%
Age- The majority of people who needed a rapid response were over 80 years old. 46% were between 80 and 90 and 22% were over 90.
Home situation- 59% lived alone. 22% lived independently and 36% with support from informal carers and family.

8. Who needed a rapid/ urgent response?
Heart problems- were the most common conditions in the past medical histories for this response (10% more than those who required a bed based response).
Dementia/ Cognitive Impairment- 18% of people had an existing diagnosis of Dementia and another 6% had a history of cognitive impairment. On assessment these people had medium to high levels of need around memory and cognition.
End of Life- 7% of people who needed a rapid response required it to facilitate prompt access to end of life care.
17% had currently or previously had a diagnosis of cancer.
22% had pain that was not resolved by simple analgesia. This is also the only response where people had very high needs around pain relief (2%). This could be connected to the end of life referrals.
Local Infection- 10% had a UTI, chest infection or other local infection.
Wounds- A quarter had a wound or needed some sort of dressing. The majority only needed a simple dressing, but 4% needed something more complex.

9. Who needed a rapid/ urgent response?
Reduced mobility- prior to this episode 23% were independently mobile and 54% used a walking aid. On referral to intermediate care, just under half needed supervision (40%) or physical assistance (9%) to walk. 6% were unable to mobilise at all.
Falls-41% had fallen but only one quarter had sustained a fracture and these were generally not fractured neck of femurs or fractures requiring unplanned surgery .
Social reasons led to 5% of the referrals for this group and concerns about social situation or potential safeguarding/ risk issues were identified for 6%.
Carers 3% needed a rapid response due to carer breakdown. 12% of the carers identified in this response needed formal carer support, could not continue to care or required a care package themselves.
Home environment- Over 13% required a home assessment or provision of equipment/ minor adaptations
Over half needed support with domestic activities (including meal prep) at the point of referral and 15% were fully dependent.
Just over half also needed some support with personal care. Another 21% needed significant support with personal care.

10. What types of interventions were needed?

11. What types of interventions were needed?
Medical investigations included…
X-rays
Blood tests/ urine screen
ECG
DVT investigation
Clinical interventions identified were…
Catheterisation
Antibiotic treatment (oral)
IV antibiotics.
Pain relief
Dressings

12. What types of interventions were needed?
Other types of interventions…
Access to emergency basic household equipment/ furntiure.
Facilitate downstairs living.
Advice/ education for informal carer.
Liaison with partner’s care team.
Best Interests meeting.
Care planning
Continence assessments
Joint discharge planning with hospital/ bed based service.
Mental health assessment/ Dementia review
Safe guarding assessment
Signposting/ refer to wellbeing
Refer to telecare

13. Who is needed to deliver them?
Most frequently identified
Occasionally identified
Home environment ssessment
OTs
Therapists
Community IC service
Reablement Case manager/ worker
Medical/ Clinical Review
Clinically trained falls assessor (ECP/ GP/ANP)
GPs
ECPs
Geriatician/ Frailty focussed practitioner
Settling in visit (home from hospital)
CVS
Reablement workers
Existing care provider MH worker, Dementia Navigator etc
Mobility/ transfer assessment
Physiotherapy
Manual Handling assessor
Functional/ ADL assessment
Reablement
Mental health trained
Social Care assessment/
review existing home care package
Social Care Worker
Social Worker
XXX
Provision of equipment
Physiotherapists
Reablement case managers
Any of community IC team
In-reach by community intermediate care team to facilitate discharge (home from hospital)
Community Intermediate care service
Carers assessment
Social Care Staff
Mental health workers
Access to EOL care
Appropriate to individual
MDT
Nurses
Palliative Care Team
Medication review/ advice
Falls Assessor/ ECP GP
Pharmacy
MH workers/ Psychiatrist
Clinical Intervention
ECP/ Falls Assessor
(see above)
Nurse
Access to respite
Social Care staff
Medical Investigations/ tests
Falls Assessor/ ECP/ ANP
Phlebotomy
RAPT type assessment
Community based team
Team in A&E
Capacity assessment
Mental Health
Social Care

14. What patients told us…

15. What GPs told us…
Single point of contact with one number- which can then sign post to all services
Single assessment process
Health social care team- joint
Same day assessment or led by need
Anyone can refer to service
Period of open access to IC service post discharge
Need for care coordination  and care planning
Need family to recognise their responsibility to make referrals
IC service needs to include MDT approach – use of voluntary sector & pharmacists
Need an integrated IT system- GPs only want update /request for them to do something
Skilled workforce to up-skill care home and carers to avoid unnecessary admissions
Rapid assessment to be completed by skilled clinician – ANP/ECP