A POSITIVE VIEW OF INTERMEDIATE CARE FOR OLDER

PEOPLE

JOHN YOUNG

Consultant Geriatrician

Bradford

Patient and service need

Feasibility and effectiveness

New paradigm of care

The “proper care and rehabilitation of these (elderly) patients”

Warren, Lancet 1946

Elderly care medicine as the largest specialty

Living at home 1.8 (1.3 - 2.53)

Reduced mortality 0.65 (0.46 – 0.91)

Improved physical

Function

1.63 (1.0 – 2.65)

Improved cognitive function

2.0 (1.13 – 3.55)

Hospital Geriatric Unit v Alternative Care

Odds Ratio (95% confidence limits) at 6 months

Meta-analysis of 5 studies (n=1090)

Stuck et al Lancet 1991

SERVICES RECEIVED BY FRAIL OLDER PEOPLE (N=821)

3 MONTHS POST-DISCHARGE

• CHIROPODY• COM. NURSE• GP HOME VISIT• SOCIAL WORKER• HOME CARE

47%23%34% 5%44%

• REHAB. INPUT ??

THE EXPERIENCE OF COMMUNITY CARE

• Piles of unmet need

• Fragmented service provision

• Poor co-ordination of services

• More caring/doing, less enabling/facilitating

• Multiple assessments

• Multiple waiting lists

BASIS FOR INTERMEDIATE CARENo. 1

UNEQUIVOCAL, UNARGUABLE, UNCONTESTABLE

PATIENT NEED

TO TRANSFORM COMMUNITY SERVICES FOR OLDER PEOPLE

“Hospitals, Jim, but not as we know them.”

Vetter, 1997

BASIS FOR INTERMEDIATE CARENo. 2

UNEQUIVOCAL, UNARGUABLE, UNCONTESTABLE

SERVICE NEED

TO TRANSFORM COMMUNITY SERVICES FOR OLDER PEOPLE

OUR HEALTH SERVICE IS

OBSSESSED WITH

BEDS….beds

……….beds

……………beds

…………………beds

“Please Sir, can I have some more beds?”

“If we always do what we’ve always done,

We’ll always get what we’ve always got.”

Don Burwick

THE INTERDEPENDENCE OF SERVICESYoung, BMJ 2001

PRIMARY CARE

SECONDARY CARE

SOCIAL SERVICES

I.C.

WHOLE SYSTEMS THINKING

Multi-agency working

BASIS FOR INTERMEDIATE CARENo. 3

NEW PARADIGM OF CARE FOR OLDER PEOPLE

Whole systems working

Multi-agency

Person centred care

Single assessment process

“New ways of working”

Joint budgets, staff, equipment etc.

BASIS FOR INTERMEDIATE CARENo. 4

FEASIBILITY

(Not a set of abstract concepts)

CONFIRMED EXPANSION OF I.C.

TARGET

2004

BEDS +5,000

PLACES +1,700

PTS. +220,000

Capacity targets due to be met in 2004

Hansard, April, 2004

2004

+8,697

+17,339

+331,721

THE EVOLUTION OF I.C.(Needs time)

EMBRYONIC SERVICE(S)

DEFINED I.C. COMPONENTS

WHOLE SYSTEM I.C.

INTEGRATED WHOLE SYSTEM I.C.

(= Multi-agency working)

(=Criteria driven IC)

(=Single telephone & person driven IC)

(=Mainstream service)

IN MATURE I.C. SERVICES (=critical mass & integrated)

Favourable service level outcomes reported:

- Lower DGH demand- Lower care home demand

BASIS FOR INTERMEDIATE CARENo. 5

EFFECTIVENESS

(As a clinical service)

Hosp. at Home v inpatient hospital care

(Cochrane review: Sheppard & Iliffe)

N = 16 RCTs

How many trials do you want?

EXPERIMENTAL EVIDENCE FOR I.C.

SUMMARY OF HaH FINDINGS

• Feasible

• Flexible: diff. conditions

diff. IC functions

• Clinically safe service

• Similar cost to in-patient care (?) 

• Offers genuine alternative to in-patient care

• Increases local health service capacity• Cochrane review: Sheppard & Iliffe

I.C. as a vector for whole

system changes

INTERMEDIATE CARE INTERMEDIATE CARE IS NOT A SCARY IS NOT A SCARY

BUSINESSBUSINESSBasis for I.C.:

• Pressing pt & service need for change

• I.C. as a feasible & effective response

• I.C. as a paradigm shift in community care for OPi.e.

to infiltrate existing services and so create an influence on attitudes, behaviour and skill-base for older people