1. Mr Chris Hill Torfaen Joint intermediate care manager

2. Encompasses a range of services managed within an established and co-ordinated system of care so that there is early engagement with need based on assessment and provision of multi-sectoral care. What is Intermediate Care – NSF Wales 2005 DEFINITION

3.  Audit commission report (1997): The coming of age: Improving care services for older people. There was too little investment in preventative and rehabilitative services leading to unplanned admissions of older people to hospital and premature admission to long term residential care.  Department of Health National Bed Enquiry (2000): Shaping the future of the NHS. For Older people around 20% of bed days were probably inappropriate and would be unnecessary if alternative facilities were in place and close to home.

4. NSF Older people England 2001 Standard three Intermediate Care Department of Health (2002) Intermediate Care: Moving forward Welsh Assembly Government (2001) – Improving health in Wales – A plan for the NHS with it’s partners.

5. Welsh Designed for life Welsh WANLESS report Welsh Older Persons Strategy Welsh Health Social Care and Well Being Strategy Welsh Health Circular (2002) 128 – Intermediate Care guidance Welsh NSF for older people 2005

6. INTERMEDIATE CARE Acute Hospital Unnecessary Admissions Inappropriate Bed occupancy (DTOC) Right place Right time Right people Right service INTERMEDIATE CARE Facilitate Discharge National Policy

7. Service Primarily Directed to Elderly Care 65% of all hospital beds used by patients over the age >65. Patients over the age of 75 use up 66% of the Social Services expenditure 75% of non-elective hospital beds used by the chronically ill.

8.  Help prevention of deterioration and crisis  To avoid inappropriate hospital admission  To avoid inappropriate care home admission  Facilitate early discharge or transfer of care to a more appropriate setting for rehabilitation  Maximise people’s independence  Maintain independence ETHOS: ETHOS

9. We believe expansion of Intermediate Care is important to the efficiency and effectiveness of the health and social care system. It will enable: 1. more effective use of acute capacity 2. supporting targets on waiting times 3. to respond more effectively to emergency pressures 4. more effective us of capacity in continuing health care and long-term care as part of a wider set of measures to reduce dependency and institutionalisation. Developing a service model

10. The core team Clinically led by a consultant geriatrician. 1 SpR on training rotatation 6 experienced clinical assessors 2 skilled clinical support workers Admin support Providing a rapid response when needs arise. Deterioration in health or social circumstances. Essential: 1. Rapid Assessment 2. Diagnosis 3. Immediate treatment 4. Refer to the most appropriate services

11. Reablement team Physio O/T Nurse CPN Reablement assistants COPD/Respiratory services Tele-health/care services Environment assessment and adaptations team. Falls services Long term conditions teams Emergency care at home – social care service. And many more collocated with a single point of contact.

12. Response times: Prioritise 1 12 hours Prevent admission Early discharge Prevent admission to care homes Prevent admission Early discharge Prevent admission to care homes Sub-acute patients (Not acutely ill to be admitted to hospital) VIRTUAL WARD ROUND Resident at own home, care homes or Sheltered housing Diagnostics General Practitioner IV antibiotics Out of Hours Service Out of Hours Service Palliative Care Minor injury SINGLE POINT OF ACCESS Assessors, Consultant Geriatrician Specialist Registrar REFERRING BODIES GP DISTRICT NURSE SOCIAL WORKER HOSPITAL THERAPIST TEAMS REFERRING BODIES GP DISTRICT NURSE SOCIAL WORKER HOSPITAL THERAPIST TEAMS Step up to Admit County Step up to Admit County DLN Facilitated Discharge DLN Facilitated Discharge EMI Specialist Nurses COPD Stroke Heart Failure Specialist Nurses COPD Stroke Heart Failure Reablement Team Emergency Social Care Voluntary Services Ambulance Advanced practitioner At home Resource Centre Beds Day Care (Targeted)

13. Acute Clinical Assessment Team General Practitioners, Acute Clinicians, Allied Health and Social Care Teams, Care Homes, Voluntary Services, Supported Accommodation etc Torfaen Hospital Admission Avoidance Scheme Steering Board LHB, Trust, Social Service, GP, Consultant & Voluntary Bodies Intermediate Care Directorate Clinical Director, Borough Manager, Senior Nurse & Senior Social Workers Co-Located Teams

14.  GP’s  Health and social care teams  Assessors carry out a full medical assessment including all appropriate diagnostics. (Rapid access)  All patients are part of a virtual ward and are discussed with the consultant regarding interventions, risk and treatment plans  GP’s fully aware of contact, interventions, treatments and discharge planning arrangements.  Clinically GP’s remain responsible for their patient.

15. Delivery of Clinical Futures (Reduction of acute beds) TRANSFER Creation of virtual beds and ward in the Community Problem: Increasing emergency admission Elderly Problem: DTOC Delayed discharge (old and very old) “Blocked Beds” Responding to Pressure

16. Torfaen GP Admissions >75 years Variances between Jan-Aug 2006 – Jan-Aug 2007 OUTCOME GP ADMISSIONS Jan-Aug 2006Jan-Aug 2007 6.30pm-9am241129 9am – 6.30pm441211 Source of admission Jan-Aug 2006 Jan-Aug 2007 Variance A&E646406-240 GP682340-342 Other6434-30 Total1392780-612

17. Admissions saved from January 2007 – April 2008 LOSBed days x cost Cost for NHS bed occupancy Cost of ACAT Team Variance 1 Day975 x 262£255,450£455,690- 200,240 2 days975 x 262 x2£510,900£455,690 + 55,210 5 days975 x 262 x5£1,277,250£455,690+ 821,560 10 days975 x 262 x10£2,554,500£455,690+ 2,098,810 12 days975 x 262 x12£3,065,400£455,690+ 2,609,710 15 days975 x 262 x15£3,831,750£455,690+ 3,376,060

18. WHOLE SYSTEM APPROACH LOCAL INTEGRATED PLANNING/COMMISSIONING/EVALUATION Primary Care LHB/PCT Secondary Care Social Care Intermediate Care Voluntary Care

19. Thank you for your kind attention Please do not hesitate to contact either Chris Hill – Joint intermediate care manager Chris.hill@torfaenlhb.wales.nhs.uk 01495 332377 Professor Bim Bhowmick – Consultant Geriatrician and clinical director for Torfaen intermediate care services on 01495 765712