1. Short term/ intensive response -information for design workshops

2. 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 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.

3. 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

4. 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.
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.
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.
Rapid Assessment and Time Limited interventions Team (RATL) North Lincolnshire & Goole NHS Trust
@home service, Guys and St Thomas, London

5. 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.

6. 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

7. 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
Liaison with other services and referring on
Rehabilitation included…
Rehabilitation after surgery
Stroke and neuro rehab
Rapid access to orthortics

8. 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

9. What patients told us…