INTERMEDIATE CARE Dr Eugene Mooney by bak27323


    Dr Eugene Mooney

• Intermediate Care refers to
      “care provided to individuals outside the acute setting”

• Intermediate Care is a
       “range of integrated services to prevent unnecessary
  admission to hospital, promote faster recovery from
  illness, support timely discharge, and maximise
  independent living”

• Demand for information;

• Purpose of the collection;

• Development of the collection; and,

• The Way Forward.
                   Demand for Information
•   DHSSPS requires information to monitor intermediate care
    services on a regional basis to ensure that services are;
    – Representative of a patient-centredness approach;
    – Flexible to individual needs;
    – Reduce unnecessary admissions to hospital;
    – Facilitating early discharge;
    – Maximising independence of individuals;
    – Provided within time scales; and,
    – Not seen as “Indeterminate Care (Dustbin Service)”.
               Purpose of Collection

• Evaluate Intermediate Care Schemes, i.e. possible
  outcome measures such as services received on entry and
  services received on discharge from Intermediate care;

• Track individuals, i.e. identify re-admissions to hospitals,
  other intermediate care schemes etc; and,

• Effect of Intermediate Care, i.e. if IC had not been
  available the patient would have spent X number of days in
                    Development of the
• Literature Review, i.e. has there been any similar type
  projects carried out;

• Information Required, i.e. specific data items required;

• Defining the Process, i.e. how are clients cared for in
  intermediate care to allow us to track all clients;

• Current Information Systems, i.e. consultation to
  identify current monitoring arrangements within Trusts;
                    Information Required

•   Personal Details, i.e. gender, date of birth, postcode;

•   Referral Details, i.e. source of referral, reason for referral;

•   Intermediate Care Service, i.e. type of scheme, key dates such as
    start of IC assessment, assessment determination;

•   Services received on Discharge from Intermediate Care, i.e.
    identify delays in provision of continuing care needs
                        Personal Details

•   Client Level Information, enable detailed tracking of clients;

•   Personal Identifier, i.e. SOSCARE no, Health & Social Care Number to
    avoid double counting and enable tracking;

•   Additional information on personal characteristics, i.e. gender, date
    of birth, postcode; and,

•   Source of Referral, i.e. from Acute services or Community services
    detailing service currently being provided.
Personal Details
                    Referral Details

• Source of Referral, acute / community, detailing current
    services received;

• Date of Referral to ICS, i.e. to monitor delays in
    processing referrals by ICS;

•   Identify Referrals not Accepted, i.e. reason not
Referral Details
                  Intermediate Care
                 Services Information
• Date of Start of Assessment within ICS, i.e. begin of assessment
  of continuing care needs and entry to intermediate care;

• Package of Care on Acceptance to ICS, i.e. OT, Physio,
  Rehabilitation, Nursing Care, etc;

• Date of Assessment of Long Term Care Needs Completed, i.e.
  individuals continuing care needs identified;

• Clients Assessed Needs, i.e. residential care, reduced domiciliary
  care package etc.
              Intermediate Care Services

• Date Discharged from ICS, i.e. when did the client leave the IC

• Package of Care on Discharge from ICS, i.e. OT,
  Rehabilitation, Nursing Care, Physio, etc. This will be used to
  identify any waiting lists in relation to the clients assessed need;

• If Discharged to Hospital, i.e. reason admitted / re-admitted to
Intermediate Care Details
Intermediate Care Details
                        Possible Problems

•   Need to Develop IT and Communications Systems, i.e. when did the client
    leave the IC setting;

•   Rationalisation of Schemes in NI, i.e. universal naming conventions for

•   Clear Definition of Intermediate Care, i.e. ensure all Trusts are counting on a
    like for like basis; and,

•   Access a Single Patient Record.
                 Possible Outcome Measures

•   Bed Days Saved, i.e. by providing Intermediate Care X number of bed
    days were saved;

•   Quality of Life Outcomes, i.e. sense of personal identity, social
    integration, social contact, sense of autonomy; and,

•   Re-admission to hospital or other intermediate care scheme;

•   Level of Service provision on discharge, i.e. less intensive service
    required by client is more cost effective.
                         The Way Forward
•   Further Consultation with Trusts, i.e. currently there are reporting
    mechanisms in place but these differ between HSS Trusts and HSS Boards,
    whilst we are focused on a regional perspective;

•   User Experience Survey?;

•   Impact of RPA;

•   Development of IT Systems to Manage Information, i.e. current information
    systems are not easily adaptable, lack of consistent systems for recording and
    of agreed definitions in HSS Trusts; and,

•   Access a Single Patient Record.

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