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A short step from home

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Helen McCloughry DipCOT, SROT, MEd (Nottingham).

Intermediate Care Service Manager, Nottingham City Primary Care Trust

Nottingham has been developing intermediate care services since 1997 (Box 1). Our early services included a community rehabilitation service that focused on early discharge and crisis avoidance, and a residential rehabilitation service run by social services staff.

Nottingham has been developing intermediate care services since 1997 (Box 1). Our early services included a community rehabilitation service that focused on early discharge and crisis avoidance, and a residential rehabilitation service run by social services staff.

The National Service Framework for Older People (DoH, 2001) gave us the impetus and local finances to combine the intermediate care services pioneered locally and to develop a local strategy.

Nottingham's health and social community includes two large acute hospitals, four primary care trusts (PCTs) and two local authorities. The first priority was to persuade all stakeholders to sign up to our strategy, which involved integrating services. We now have a joint investment plan for the next three years.

Establishing a management infrastructure was crucial. It involved introducing two service manager posts, one for the borough PCTs and one for the city PCT, jointly funded with social services. Team leaders report to the service managers.

We are also investing in integrating the PCT and social services IT. There are plans to pool budgets and the service has been registered, using Health Act Flexibilities, as an integrated partnership.

Services organisation
Six health and social care multidisciplinary teams provide intermediate care in Nottingham and the surrounding boroughs.

There is a central duty and referral point with a single telephone number. We have an on-call duty clinician and we operate seven days a week 7am-10pm. We have close links with discharge planning teams in the acute trusts and we regularly access the day hospitals.

Forty people at any one time can benefit from our service in their homes. There are also 60 beds in a residential setting dedicated to intermediate care, 20 of them in Highfields Nursing Home, a 40-bed independent-sector care home, which offers nursing and residential care.

Over three years ago, the home became involved with our service by opening 10 beds for trauma and orthopaedic patients with lower-limb fractures who would be non-weight-bearing for some time. It has now added 10 more assessment beds, targeted at clients who would benefit from a longer assessment period and rehabilitation. Clients usually come directly from A&E, and avoid hospital admission.

Changing practices
Working with a large acute hospital's A&E and orthopaedic departments posed significant challenges to Highfields staff. For the manager, the shift from a care environment to an 'enabling' environment with a different skill-mix, was a big challenge.

Building trust between the teams and learning about each other's roles was essential. This involved moving from a 'them and us' to a 'we' culture. Regular review meetings are held to discuss improvements.

Domestic staff were faced with having to prepare rooms rapidly owing to high patient turnover, while catering staff had to review the menus, as they now needed to cater for clients who had previously been fit and active rather than for the frail elderly.

The staffing structure also needed to change to make the matron supernumerary as there were now greater demands on her management time.

Multidisciplinary input
Initially, the community team provided the rehabilitation but, as the service developed and the number of beds increased, more of the team became based in the unit. The team now consists of a physiotherapist, an occupational therapist, a social worker and rehabilitation support workers.

The home has access to primary care dietitians, tissue viability and continence advisory services, and specialist nurses in mental health. Highfields staff provide nursing and care input.

At the start of the service, assessments were often duplicated. Training sessions were soon in place for everyone to be clear about their roles.

The local GP has been supportive from the start and the surgery provides cover for all residents in intermediate care. Highfields nurses do patient checks and provide the GP with a background history of medical problems and a drug history. The GP addresses day-to-day issues such as urinary tract infections, chest infections or analgesia.

All GP records are kept at Highfields. On discharge, medical records are returned to the hospital and multidisciplinary notes are kept in the unit. GP records are returned to the surgery to be forwarded to the patient's GP.

A consultant in health care of the elderly also has a weekly surgery at the home. This enables results to be accessed quickly. Trauma and orthopaedic clients remain with their own consultant until discharge.

The hospital pharmacy and the community pharmacist provide cover. New systems and protocols have been developed for obtaining, administering tracking and disposing of drugs.

Handover
Easy access to beds is a major factor in the success of intermediate care. The one-stop referral service administrator checks bed availability daily and emails the hospital. After checking availability, the hospital referrer calls the home manager. Following a handover, the hospital organises transport.

Intermediate care provides a range of services. The patient usually has a period of recovery and recuperation, before having a full assessment. The service is person centred, so goals are set in conjunction with the client. The aim is usually to return home. Problem-solving and the provision of equipment are also integral to the service.

Communication is an important factor and includes meeting the client and family/ carers to discuss progress.

The FACT team
The A&E department at Queen's Medical Centre University Hospital, Nottingham, includes the Front Door Assessment and Care Team (FACT). This team is responsible for referral to our intermediate care service. It comprises nurses, occupational therapists, OT technical instructors, physiotherapists, a social worker, a community care officer, aftercare support workers and an administrator.

It provides full functional and social assessment of the over-65s who attend A&E, ensuring full supported discharge with appropriate referrals.The team aims to fulfil Standard 3 of the NSF, which calls for supported timely discharge, prevention of unnecessary hospital admissions and referral for ongoing rehabilitation for older people.

The team also helps signpost appropriate wards for older people requiring admission.

Patients discharged from A&E outside the service operating hours (Monday to Friday, 8am-6pm) have a telephone assessment from the aftercare support workers to determine their needs. They are then either referred back to FACT or to primary care services. The service also ensures links are maintained with GPs.

Future plans
Almost 1800 people have benefited from the intermediate care service in the past year. Our strategy aims to increase this figure by improving access to intermediate care.

Intermediate care is a complex intervention that only succeeds when staff and agencies co-operate and problem solve together across organisational boundaries to benefit patients. u

Department of Health. (2001) National Service Framework for Older People. London: DoH.

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