Bridging the divide Intermediate care is key to unblocking acute sector ‘gridlock’. It is also an area where nursing could come into its own. Daloni Carlisle reports the right service for their needs at the right time, unblocking the gridlock in acute hospitals and ensuring that life-changing decisions about long-term care needs are not made prematurely,’ says Dr Oliver. He points out that there is no point tracking ‘hypothetically
SUMMARY
When the National Audit of Intermediate Care Report 2013 was published in November last year, it was declared ‘an absolute must read’ by the well-known consultant geriatrician and champion of vulnerable older people David Oliver. The audit pointed out that there is only approximately half of the intermediate care capacity needed in England to avoid admitting older, frail people to hospital. It demonstrated that even where there are services, they do not always deliver the experience that patients hope for. ‘Intermediate care is crucial for ensuring that older people with complex needs are seen by
22 january 15 :: vol 28 no 20 :: 2014
Nurses have exciting roles to play in the growing emergence of intermediate care for older, frail people and those with complex needs. By overseeing capacity in community and acute services, and liaising with other professionals, they can put together care packages that avoid unnecessary hospital admissions. Author Daloni Carlisle is a freelance journalist
avoidable hospital attendance, admission or bed occupancy, or stating that people should never go straight from acute beds into nursing homes, if alternative rapidly accessible capacity is not available’. John Young, NHS England’s national clinical director for integration and frail elderly, says the national audit shows that in many health and social care communities ‘the community is full. That, of course, contributes to increased demand in A&E and hospitals’. Professor Young believes that intermediate care is an area in which nursing could come into its own. ‘Teams need to be multidisciplinary and they require input from GPs and community geriatricians. But much of the work can be done by advanced nurse practitioners, particularly those with
NURSING STANDARD
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CHRIS KEEGAN
prescribing skills,’ he says. ‘There is plenty of scope for well-trained nurses to get involved in this kind of work – it is less about job titles than about the skills that people have.’ Intermediate care is on the radar for many clinical commissioning groups. Increasingly, health and social care, nursing and care homes, and acute hospitals are being joined together in new services and pathways. In the 2013 audit sample intermediate care services were jointly commissioned in 74 per cent of health economies, compared with 58 per cent in 2012. And new and exciting roles for nurses are being created in the process.
Call centre
Teresa Moore works in a clinical co-ordination hub that serves Stafford and Stoke-on-Trent, handling calls from clinicians seeking alternatives to hospital admission for patients. Recently, she received a call from a community nurse
who was looking after a man with a chest infection who needed short-term care. ‘We discussed an intermediate care package of home visits that included four calls during the day and night visits, as well as support for his wife. We put together a package for this man, who would otherwise have gone to hospital,’ says Ms Moore. Another call was from a district nurse on a routine visit to a patient recently discharged from hospital. ‘He had fractured his shoulder and could not move from his chair. She sent him to A&E and
What is intermediate care? Intermediate care is needed by people who are too sick to remain at home, but do not need to be in an acute hospital. It is also needed by those who are occupying an acute hospital bed, but are unable to return home safely without support. It has three aims: To avoid unnecessary hospital admission. To help people regain independence after a stay in hospital. To prevent people moving into residential care prematurely.
wanted to find a support package so he could come straight home again. We sorted that out.’ Ms Moore also works with ward nurses, putting together reablement and early discharge care packages for patients.
Investment
The hub, commissioned by North Staffordshire and Stoke-on-Trent clinical commissioning groups (CCGs) and provided by Staffordshire and Stoke-on-Trent Partnership NHS Trust, has been running since September 2013. The CCGs have also invested in intermediate care services. The hub is making an impact. In one week in November it handled 158 referrals from healthcare professionals seeking an alternative to hospital admission for urgent care patients. Of these, 138 were managed without a non-elective admission, including 95 per cent of the 68 GP referrals and 97 per cent of 38 referrals from ambulance crews. ‘My job is about having clinical conversations,’ says
NURSING STANDARD january 15 :: vol 28 no 20 :: 2014 23 Downloaded from RCNi.com by ${individualUser.displayName} on Nov 28, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Ms Moore. ‘I feel that I am in a helicopter hovering over all the community services. I can see exactly what the capacity is in the community and the acute sector and match it to people’s needs.’ In Cornwall, nurse practitioners Marie Prior and Tracy Hind reduce emergency hospital admissions from nursing and residential care homes in a service commissioned by Kernow CCG and provided by Peninsula Community Health. ‘Our role is to make sure that residents are medically managed and to provide nursing leadership for the staff,’ says Ms Prior. ‘We are trying to embed clinical changes and standards – and it is time-intensive.’
All-round help
Ms Hind says: ‘Often we are helping with basic things, such as education on hydration and nutrition. But sometimes we help with things that staff find difficult, such as analysing whether an admission was appropriate and, if not, what could have been done differently.’ Such input can help to avoid unnecessary hospital admissions. Ms Hind gives the example of a home where a man
needs assessments and develop intensive packages of care with physiotherapists and district nurses where they are needed. ‘The advantage of a nursing home setting is the social aspect. People eat together and there are activities on offer. It makes a big difference to recovery.’
was admitted with a suspected abdominal aortic aneurism and staff were told to call the emergency services if he had severe stomach pains. Staff had not been provided with medical information and felt daunted by the situation. ‘I reviewed all the notes and could not find any diagnosis. The staff asked if he could have a scan – it is the sort of thing that is difficult for them to
Collaboration
‘THERE IS PLENTY OF SCOPE FOR WELL-TRAINED NURSES TO GET INVOLVED IN THIS WORK’ – John Young organise – so I managed that. There was no aneurism. They were so relieved.’ The use of nursing homes to provide intermediate care is not new, but it is a growing trend. Trish Morris-Thompson, chief nurse at Barchester Healthcare, which owns 224 homes, says the challenge is local variability. ‘We have some great models of care, where commissioners work with us to provide intermediate care – either step up to avoid an admission or step down to assist a discharge,’ she says. ‘We undertake joint
Variability is also a concern for RCN assistant head of nursing Tim Curry. The national audit flagged up variation in the nursing capacity and capability within intermediate care – a situation that needs attention, he says. ‘We are still preparing nurses to work in particular ways and in particular settings, and there is a predominance of acute managerial leadership. ‘The community is not just a small hospital. We need to look at how nurses can work and lead in more collaborative ways.’ Excellent examples of intermediate care should be taken up elsewhere, he says. ‘We need the research to validate them and the tools for scaling up, as well as workforce modelling. We need to understand information pathways. There is a long way to go’ NS
Frail elderly care pathway results in a seamless service Northumberland CCG has developed a frail elderly pathway to join up care and avoid hospital admissions. Healthcare professionals identify patients at risk of unnecessary hospital admission – perhaps because of calls to the out-of-hours service or a visit to the emergency department. Each ‘at risk’ patient receives a structured assessment that covers aspects such as mobility, nutrition, depression and memory impairment. They receive the same assessment regardless of which healthcare professional carries it out, or where. Care packages are then built around their needs. These include input from community nursing, primary care, 24 january 15 :: vol 28 no 20 :: 2014
social care and pharmacy staff, with regular review by a primary care-based multidisciplinary team. Olive Lightly, community matron and practice teacher at Northumbria Healthcare NHS Foundation Trust, explains: ‘I work with GPs and health and social care workers to ensure people who come out of hospital, or are at risk of hospital admission, are supported at home to stay safe and well. ‘I carry out assessments in patients’ homes, ensure they have the correct medication and relevant equipment, and monitor their condition. I also liaise with patients, their GPs and other professionals involved in
their care, keeping them up to date with the situation, and make the necessary arrangements if any risks are identified. ‘The improved communication links between health and social care teams mean that patients have a seamless service. ‘It is structured, evidence-based care, and patients and families who have been involved have all said how beneficial and supportive they have found this new way of working.’ The pathway was introduced more than a year ago, alongside some other changes. Since then, Northumbria has driven its unnecessary admissions rate down to below average.
NURSING STANDARD
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SUMMARY
When the National Audit of Intermediate Care Report 2013 was published in November last year, it was declared ‘an absolute must read’ by the well-known consultant geriatrician and champion of vulnerable older people David Oliver. The audit pointed out that there is only approximately half of the intermediate care capacity needed in England to avoid admitting older, frail people to hospital. It demonstrated that even where there are services, they do not always deliver the experience that patients hope for. ‘Intermediate care is crucial for ensuring that older people with complex needs are seen by
22 january 15 :: vol 28 no 20 :: 2014
Nurses have exciting roles to play in the growing emergence of intermediate care for older, frail people and those with complex needs. By overseeing capacity in community and acute services, and liaising with other professionals, they can put together care packages that avoid unnecessary hospital admissions. Author Daloni Carlisle is a freelance journalist
avoidable hospital attendance, admission or bed occupancy, or stating that people should never go straight from acute beds into nursing homes, if alternative rapidly accessible capacity is not available’. John Young, NHS England’s national clinical director for integration and frail elderly, says the national audit shows that in many health and social care communities ‘the community is full. That, of course, contributes to increased demand in A&E and hospitals’. Professor Young believes that intermediate care is an area in which nursing could come into its own. ‘Teams need to be multidisciplinary and they require input from GPs and community geriatricians. But much of the work can be done by advanced nurse practitioners, particularly those with
NURSING STANDARD
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 28, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CHRIS KEEGAN
prescribing skills,’ he says. ‘There is plenty of scope for well-trained nurses to get involved in this kind of work – it is less about job titles than about the skills that people have.’ Intermediate care is on the radar for many clinical commissioning groups. Increasingly, health and social care, nursing and care homes, and acute hospitals are being joined together in new services and pathways. In the 2013 audit sample intermediate care services were jointly commissioned in 74 per cent of health economies, compared with 58 per cent in 2012. And new and exciting roles for nurses are being created in the process.
Call centre
Teresa Moore works in a clinical co-ordination hub that serves Stafford and Stoke-on-Trent, handling calls from clinicians seeking alternatives to hospital admission for patients. Recently, she received a call from a community nurse
who was looking after a man with a chest infection who needed short-term care. ‘We discussed an intermediate care package of home visits that included four calls during the day and night visits, as well as support for his wife. We put together a package for this man, who would otherwise have gone to hospital,’ says Ms Moore. Another call was from a district nurse on a routine visit to a patient recently discharged from hospital. ‘He had fractured his shoulder and could not move from his chair. She sent him to A&E and
What is intermediate care? Intermediate care is needed by people who are too sick to remain at home, but do not need to be in an acute hospital. It is also needed by those who are occupying an acute hospital bed, but are unable to return home safely without support. It has three aims: To avoid unnecessary hospital admission. To help people regain independence after a stay in hospital. To prevent people moving into residential care prematurely.
wanted to find a support package so he could come straight home again. We sorted that out.’ Ms Moore also works with ward nurses, putting together reablement and early discharge care packages for patients.
Investment
The hub, commissioned by North Staffordshire and Stoke-on-Trent clinical commissioning groups (CCGs) and provided by Staffordshire and Stoke-on-Trent Partnership NHS Trust, has been running since September 2013. The CCGs have also invested in intermediate care services. The hub is making an impact. In one week in November it handled 158 referrals from healthcare professionals seeking an alternative to hospital admission for urgent care patients. Of these, 138 were managed without a non-elective admission, including 95 per cent of the 68 GP referrals and 97 per cent of 38 referrals from ambulance crews. ‘My job is about having clinical conversations,’ says
NURSING STANDARD january 15 :: vol 28 no 20 :: 2014 23 Downloaded from RCNi.com by ${individualUser.displayName} on Nov 28, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Ms Moore. ‘I feel that I am in a helicopter hovering over all the community services. I can see exactly what the capacity is in the community and the acute sector and match it to people’s needs.’ In Cornwall, nurse practitioners Marie Prior and Tracy Hind reduce emergency hospital admissions from nursing and residential care homes in a service commissioned by Kernow CCG and provided by Peninsula Community Health. ‘Our role is to make sure that residents are medically managed and to provide nursing leadership for the staff,’ says Ms Prior. ‘We are trying to embed clinical changes and standards – and it is time-intensive.’
All-round help
Ms Hind says: ‘Often we are helping with basic things, such as education on hydration and nutrition. But sometimes we help with things that staff find difficult, such as analysing whether an admission was appropriate and, if not, what could have been done differently.’ Such input can help to avoid unnecessary hospital admissions. Ms Hind gives the example of a home where a man
needs assessments and develop intensive packages of care with physiotherapists and district nurses where they are needed. ‘The advantage of a nursing home setting is the social aspect. People eat together and there are activities on offer. It makes a big difference to recovery.’
was admitted with a suspected abdominal aortic aneurism and staff were told to call the emergency services if he had severe stomach pains. Staff had not been provided with medical information and felt daunted by the situation. ‘I reviewed all the notes and could not find any diagnosis. The staff asked if he could have a scan – it is the sort of thing that is difficult for them to
Collaboration
‘THERE IS PLENTY OF SCOPE FOR WELL-TRAINED NURSES TO GET INVOLVED IN THIS WORK’ – John Young organise – so I managed that. There was no aneurism. They were so relieved.’ The use of nursing homes to provide intermediate care is not new, but it is a growing trend. Trish Morris-Thompson, chief nurse at Barchester Healthcare, which owns 224 homes, says the challenge is local variability. ‘We have some great models of care, where commissioners work with us to provide intermediate care – either step up to avoid an admission or step down to assist a discharge,’ she says. ‘We undertake joint
Variability is also a concern for RCN assistant head of nursing Tim Curry. The national audit flagged up variation in the nursing capacity and capability within intermediate care – a situation that needs attention, he says. ‘We are still preparing nurses to work in particular ways and in particular settings, and there is a predominance of acute managerial leadership. ‘The community is not just a small hospital. We need to look at how nurses can work and lead in more collaborative ways.’ Excellent examples of intermediate care should be taken up elsewhere, he says. ‘We need the research to validate them and the tools for scaling up, as well as workforce modelling. We need to understand information pathways. There is a long way to go’ NS
Frail elderly care pathway results in a seamless service Northumberland CCG has developed a frail elderly pathway to join up care and avoid hospital admissions. Healthcare professionals identify patients at risk of unnecessary hospital admission – perhaps because of calls to the out-of-hours service or a visit to the emergency department. Each ‘at risk’ patient receives a structured assessment that covers aspects such as mobility, nutrition, depression and memory impairment. They receive the same assessment regardless of which healthcare professional carries it out, or where. Care packages are then built around their needs. These include input from community nursing, primary care, 24 january 15 :: vol 28 no 20 :: 2014
social care and pharmacy staff, with regular review by a primary care-based multidisciplinary team. Olive Lightly, community matron and practice teacher at Northumbria Healthcare NHS Foundation Trust, explains: ‘I work with GPs and health and social care workers to ensure people who come out of hospital, or are at risk of hospital admission, are supported at home to stay safe and well. ‘I carry out assessments in patients’ homes, ensure they have the correct medication and relevant equipment, and monitor their condition. I also liaise with patients, their GPs and other professionals involved in
their care, keeping them up to date with the situation, and make the necessary arrangements if any risks are identified. ‘The improved communication links between health and social care teams mean that patients have a seamless service. ‘It is structured, evidence-based care, and patients and families who have been involved have all said how beneficial and supportive they have found this new way of working.’ The pathway was introduced more than a year ago, alongside some other changes. Since then, Northumbria has driven its unnecessary admissions rate down to below average.
NURSING STANDARD
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