Service Models for Intermediate Care
An excellent experience for medically stable patients
Our intermediate care services support people by helping them to achieve their independence and return to their own homes as soon as possible. Our aim is to empower individuals and build their confidence by helping them to set their own goals, while at the same time addressing their health and social care needs.
Every person working on our intermediate care services works to a reabling ethos
The culture we create is both person-centred and dementia-friendly. Every single interaction is used as an opportunity to build confidence and relearn skills. This allow us to:
- facilitate discharges from hospital to an out-of-hospital care setting, reducing the incidence of delayed discharges and transfers of care
- prevent or divert admissions to out-of-hospital care and reduce unplanned care admissions into acute NHS hospitals
Our Intermediate Care service models provide emotional benefits for people and cost savings for the NHS
- High quality care is shifted closer to home, from acute into community settings
- Provide ‘acute community beds’ as virtual wards away from hospital
- Prevent admissions from care homes into acute hospital settings
- Provide end-of-life and palliative care beds in homely surroundings reducing the numbers of patients dying in hospital
- Support the care pathway for people with long term conditions. This improves their quality of life and health while promoting choice and more personalised approaches to management and wellbeing
- Provide safe intermediate and longer term care and support for people with dementia out of hospital
Outcomes with measurable effectiveness and cost savings
- By diverting acute hospital bed admissions, patients receive the nurse-led intervention they need to return to their normal home setting as quickly as possible. This intervention will be linked to each patient’s reason for admission and required treatment, for example IV antibiotics to treat an infection.
- To support transfer of care and prevent delayed discharges we will work with CHC teams and local authority social care teams to help facilitate the rapid planning of each patient’s onward final care destination. We will also provide the required care and support to enable this process, for example provision of rehabilitation following a fall or a stroke.
Specific targets related to length of stay can be incorporated into the contracting arrangement.
Read more on our intermediate care service