York St John University | www.yorksj.ac.uk

Best practice for

community living

through

Intermediate care

and reablement:

A complex case

discussion

Fiona Howlett

May 2012

1 www.yorksj.ac.uk

Plan for the session

• Brief summary of intermediate care and

reablement

• Discussion around complex case scenario

• Implications for the work/resources

required

www.yorksj.ac.uk 2

What is Intermediate Care?

• Intermediate care is a range of integrated

services designed to:

• promote faster recovery from illness

• prevent unnecessary acute hospital admission

and premature admission to long-term

residential care

• support timely discharge from hospital and

maximise independent living.

3 www.yorksj.ac.uk

Essential elements within

Intermediate Care Services are locally based

Care provided close to home

Focus is on restoring or maintaining

function

Rehabilitative approach

Services are short term

Multi professional/multi

agency teams

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Key drivers for the development

of Intermediate Care

Pressure on acute hospital

beds

NHS financial pressures

Local authority financial

pressures

More older people with long

term chronic conditions

Patient choice Reimbursement

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Intermediate care services are

based on: • Comprehensive, multi professional, multi agency

assessment - in line with the single assessment

process (DH 2001)

• Provision of a structured individual treatment

plan which includes active therapy, treatment or

opportunity for recovery.

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How is Reablement different to

Intermediate Care Services?

• Services for people with poor physical or mental

health to help them accommodate their illness

by learning or re-learning the skills necessary for

daily living. (Care Services Efficiency Delivery

programme 2007)

• Helping people to maximise their independence, choice and quality of life

• Helping people to remain in their own homes

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Reablement

• Providing time limited interventions with services

tailored to individual’s needs (Care Service

Efficiency Delivery programme 2007

• Reablement ‘seeks to maximise long term

independence, choice and quality of life, whilst

minimising the ongoing support required’

Pilkington 2008 p.355

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How does this differ from

Intermediate care?

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Hospital (secondary care)

Intermediate care (may be primary

or secondary care depending on

location)

Reablement

(Predominantly Social care)

Guiding principles

• Person-centredness: Service users should have

more control and choice over their support

• The role of adult social care is to help people to

maintain or regain their independence,

regardless of age, impairment, ethnicity or

personal circumstances

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Mrs Brown

• Mrs Brown is a 68 year old woman

• Until recently she had shared her privately

rented terraced house with her partner of 20

years

• Partner had recently died in traumatic

circumstances and she was coming to terms

with her loss

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Presenting Medical Issues

• Chronic lymphodema affecting both legs.

• Both legs are ulcerated and require daily

dressing

• Osteoarthritis affecting both hips and knees

• Obesity

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Social Support systems

• No family

• Two good friends who live locally

• Mrs Brown does not know neighbours as

neighbouring properties also rented and

neighbours change frequently

• No help at home other than District Nurses who

visit daily to dress Mrs Brown’s ulcerated legs

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Presenting problems and

reasons for referral • Referral to the Intermediate care team by the

District Nurses

• Presenting difficulties were:

• She was not able to mobilise safely around her

home

• She could not access her toilet

• She could not access her bathroom

• She could not access her kitchen

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Presenting problems continued..

• Mrs Brown’s house was very cluttered and

inaccessible

• There were dogs, a cockatiel, two snakes in a

vivarium and mice running around the property

• Basic needs were met at ASDA (Wal-Mart) via

scooter

• Risks +++

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Street of terraced houses

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A fairly typical terraced house

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Narrow hallway

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Narrow stairs

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Dining room

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Galley Kitchen

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York St John University | www.yorksj.ac.uk

.

Sitting Room

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York St John University | www.yorksj.ac.uk

.

What did the team do?

• Responded to the referral within 2 hours and

completed a risk assessment

• Admitted Mrs brown to an Intermediate care

team bed in a local nursing home.

• Contacted environmental health department to

remove the dead mice and put down bait for the

living mice

• RSPCA took away the snakes and arranged

foster care for the dogs and a friend looked after

the bird in the cage www.yorksj.ac.uk 24

Mrs. Brown’s Goals

• To be able to get washed and dressed with

minimal assistance

• To be able to access the toilet and get on /off the

toilet safely

• To be able to prepare meals safely

• To be able to mobilise around her home safely

• To live in a property which meets her needs and

in which she feels safe

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Ethical Issues/

Diversity of living conditions?

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• Some individuals may stray from societal norms of cleanliness and hygiene

• What are the ethical and practical issues for professionals?

• How can you respond to the challenges?

• What are the potential solutions?

• Would you offer Mrs Brown any interventions,

and if so where?

Ethical issues in practice

• There is an ethical dimension to most of what we do in

the workplace (Hendrick 2004).

• Professionals need to be able to recognize these and

consider the implications for the individual, their families

and carers.

• Campbell, Chin and Voo (2007) identify that medical

ethics is not the concern of one professional group or

discipline but is a matter which should be approached

from a multi-disciplinary perspective having relevance to

all professionals working in health and social care.

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Resolving ethical dilemmas

• Informed by professional codes of practice

• It has been argued that Codes of conduct should be

used as a framework for guidance but cannot be

expected to resolve complex ethical dilemmas (Terry

2007).

• Supervision

• Multi disciplinary team discussion

• Grids/frameworks/models may help but need to

remember that applying ethical decision making models

does not produce bias free decisions as personal values

will still impact on upon this process (Mattison 2000)

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Need to consider..

• Balancing risk with harm

• Positive risk taking

• Respecting autonomy and choice

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What Model of practice might

you use and why?

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Person-Environment-Occupational

Performance Model

Person

Performance

Occupation

Environment

31 www.yorksj.ac.uk

Baum, Bass, Christiansen

(2005)

Person Level issues Health

Strengths

Needs

Goals

Wishes

Meanings

Risks

Environment Where/Who with?

Supports

Demands/

Home environment

Risks

Benefits

Occupational

Performance Community engagement

Occupation Activity task role

What/How/when

Supports

Preserved activities

Bingo/social outings

Risks

Benefits

32 www.yorksj.ac.uk

Canadian Model of Occupational

performance and engagement

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Townsend and Polatajko

2007

Canadian Model of Occupational

performance and engagement

• Self-care

• Washing/dressing

• Showering

• Toileting

• Productivity

• Preparing meals

• Maintaining home

• Leisure

• Walking dogs

• Going to bingo

• Social events – risk of

social isolation

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Person centred assessment

• Use active observation

– Standing back – allowing person to be themselves

and be “in the flow” of activities

– Observe the person’s own strategies, routines and

pathways and build on them

– Use activity analysis and synthesis

• Mixed methodology - Informal, formal, standardised and

dynamic

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Person centred assessment

• Working with the person in their lived environments:

• Physical environment

– creating accessible and enabling environments, role

of assistive technology and adaptations

• Social and cultural environment

– Reducing stigma

– Reducing occupational deprivation

– Promoting positive communication

– Supporting and enabling carers

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Which assessments would you

choose and why?

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Assessments

• Observation of Activities of daily living

• FIM/FAM (base line) Granger et al (1993)

• COPM (Law et al 2005)

• AMPS (Fisher 2003)

• Homefast (Mackenzie et al 2000)

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What interventions might you

choose and why?

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What interventions and why?

• Maintain or improve upper/lower limb strength, ROM

and tolerance

• Maximise ADL

• Ensure safety and accessibility in the home -

Rehousing

• Assess need and make recommendations for

equipment/adaptations

• Explore interests/reduce social isolation

• Assist with psychological adjustment to problems

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Who was involved?

• District Nurse

• Physiotherapist

• General Practitioner

• Consultant

orthopaedic surgeon

• Therapy Assistants

• Dieticians

• Environmental Health

Officers

• Local Housing

Department

• Friends

• Foster carers for the

pets

41 www.yorksj.ac.uk

Outcome

• Mrs Brown was re-housed within 8 weeks to a

local Housing Authority owned bungalow which

already had a level access shower

• A hoist was provided for the days when Mrs

Brown’s mobility was severely impaired by pain

42 www.yorksj.ac.uk

Outcome

Mrs Brown required bariatric equipment to meet

her needs:

• Wheelchair

• Shower chair

• Rise recliner chair

• Profiling bed

• Glideabout commode

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Outcome

• Mrs Brown received a package of care which involved

carers visiting 4 times each day to assist with personal

care, meal preparation and walking her dog - provided

free initially for 6 weeks

• Transferred to reablement team then to private care

team then she would need to pay for her care through

Local Authority

• Her dogs and budgie were returned to her

• The snakes were not!

44 www.yorksj.ac.uk

Implications for work/resources

• Services are free at the point of delivery

• Response times 2 hours from receipt of referral

• Therapy services 7 days per week

• Extended hours of working

• Services are time limited to 6 weeks

• Services are provided close to home or in the home

• Collaboration with the older person and their carers

essential

• Collaboration with other team members essential

• Role blurring common

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References

• Baxter S & Brumfitt S (2008) Professional differences in

interprofessional working Journal of Interprofessional Care 22 (3)

239-251

• Campbell A, Chin J and Voo T (2007) How can we know that ethics

education produces ethical doctors? Medical Teacher 29 p 431-436

• Baum C, Bass J, Christiansen C (2005) Person- environment-

occuaptional performance: a model for planning interventions to

individuals and organizations. In Christiansen C, Baum C, Bass J

(Eds) Thorofare. New Jersey.Slack inc.

• DH (2000) NHS Plan. London: The Stationary Office.

• DH (2001) National Service Framework for Older People. London: The Stationary Office.

www.yorksj.ac.uk 46

References

• DH (2005) National Service Framework for people with long term conditions. London: Stationary office

• DH (2009)Intermediate Care: Half way home London: The Stationary Office

• Fisher AG, (2003a) Assessment of motor and process skills 5th edition. Fort Collins,CO. Three Star Press

• Glendinning C,(2003) breaking down the barriers: integrating health and social care for older people in England. Health Policy 65 (2) 139-151

• Granger CV, Hamilton BB, Linacre JM, Heinemann AW, Wright BD (1993). Performance profiles of the functional independence measure. American Journal of Physical Medicine and Rehabilitation. 72(2), 84-89

www.yorksj.ac.uk 47

References

• Hoffman SJ, Rosenfield D, Gilbert JHV, Oandasan IF (2007),

Student leadership in interprofessional education; benefits,

challenges and implications for educators, researchers and

policymakers. Hughes L, Marsh L and Lamb B (2006) Creating an

Interprofessional Workforce

• Hammick M, Freeth D,Copperman J, & Goodsman D (2009) ‘Being

Interprofessional’. Cambridge. Polity Press

• Hendrick J (2004) Law and Ethics. Foundations in Nursing and

Healthcare. Cheltenham. Nelson Thornes.

• Law M, Baptiste S, Carswell (2005) Canadian occupational

performance measure. Toronto. CAOT publications.

www.yorksj.ac.uk 48

References

• Mackenzie L,Byles J, Higginbotham N, (2000) Designing the home

falls and accident screening tool. (HOMEFAST): Selecting the items.

British Journal of Occupational Therapy 63(6), 260-269

• McDermott K, Linahan K and Squires B J (2009) Older People

Living in Squalor: Ethical and Practical Dilemmas Australian Social

Work Vol 62, No 2 pp245-257

• Northern health (2004) Patients first: Optimizing Inter-professional

Team Work. Report on current practices. Prince George, BC,

Northern Health project

• Pilkington, G (2008) Home care reablement: Why and how providers

and commissioners can implement a service. Journal of Integrated

Care. 16 (2) 38-40

www.yorksj.ac.uk 49

References

• Terry L (2007) Ethics and contemporary challenges in health and

social care. In Leathard A and McLaren S (eds) Ethics and

contemporary challenges in health and social care, pp 25 Bodmin:

The Policy Press

• Townsend,EA Polatajko,HJ (2007) Enabling occupation 11:

Advancing an occupational therapy vision for health well-being and

justice. CAOT publications ACE. Ottawa ON.

• Seedhouse D (2005) The Moral Context of Practice and

Professional Relationships, In Occupation& Practice in Context

Whiteford G and Wright-St Clair (Eds) Australia Elsevier

www.yorksj.ac.uk 50

Programming

with elders:

A summary

Fiona Howlett

www.yorksj.ac.uk 51

Summary:

Programming with elders

www.yorksj.ac.uk 52

• Or, interventions with older people

• Services driven by Department of Health policy guidance

• Services driven by ageing population

• Services are designed to meet the needs of local populations

• There is not always a blueprint for how services should be

delivered

• Freedom to be able to work in a person centred way with an

older person

• Interventions are focussed on the older person’s goals

• Services remain free at the point of delivery

• Services are time limited

A thought to leave you with..

• Older people must not be left to find their way

around the hospital system or left in a hospital

bed when supported care or rehabilitation is

what they need

• They must receive the right care in the right

place at the right time. NHS Plan DH (2000)

53 www.yorksj.ac.uk