Intermediate Care of Older People

Uptake of audit
  1. What is intermediate care?
  2. Introduction
  3. Intermediate care and older people.
  4. Supplemental Content
  5. A new service in the intermediate care of older adults with mental health problems.

No significant differences in mortality HR 1.


However, there was an increased rate of readmission in the HaH group HR 1. Data from three of the trials showed that HaH was associated with a lower rate of admission to residential care at one year RR 0. Cost analyses varied across the trials depending on how they were calculated, making it impossible to formulate any general conclusions. In summary, there is no strong evidence that HaH for early discharge is any cheaper than standard care, but it appears to offer similar rates of mortality and disability.

There may be a lower chance of admission to residential care at one year, but offset by a higher risk of readmission to hospital. Patients generally seem to like HaH schemes. A number of novel approaches have been attempted to release standard acute hospital beds. A trial randomised hospital inpatients mean age No differences were seen in functional ability or discharge destination.

What is intermediate care?

A Cochrane review of this topic was unable to reach any firm conclusions. A trial randomised patients median age 86 years to a period of post-acute care within a community hospital or continuing standard care in an acute hospital. Interpreting the generalisability of studies of this type may be difficult due to the heterogeneous nature of community hospital design and staffing. During these trials the clinical staff are not blinded to patient allocation, which may introduce some bias.


Care home beds have been utilised as transitional units for patients whose discharge has been delayed due to awaiting a permanent care home place. It has been hoped that, by providing additional rehabilitation, some of this group of patients may be able to return home after all. A study randomised older people median age 81 years , who wished to return home but were thought to be at high risk of care home placement, to either have a period of rehabilitation within a care home environment or to continue standard hospital care following an acute hospital admission.

There were no significant differences in functional ability, mortality or care home placement rates after 12 months. As might have been expected, the duration of stay within the acute hospital was shorter in the intervention arm median 11 days , but the total time before placement was increased median 21 days. This strategy may increase access to acute hospital beds, but is unlikely to be cost effective given the increase in overall time in care. For these groups of patients it seems that an additional period of rehabilitation has no significant sustained benefit in functional ability.

It would probably be better to invest additional funding into care home provision to release hospital beds sooner, rather than develop this new model of continued hospital care. The available data have not shown any IC scheme to be effective at reducing acute hospital use. Although measuring outcomes and costs in complex services by conventional techniques may be too insensitive to detect genuine gains, 39 and the patients currently being admitted to IC services may not be the people most likely to benefit.

The evaluation of cost-effectiveness may depend on whether it is assessed from the perspective of primary care, acute hospitals, or society as a whole. The current UK Payment by Results PbR system typically gives a standard tariff for an inpatient episode depending on the primary diagnosis, almost irrespective of length of stay. Primary care organisations stand to benefit financially by admission avoidance, secondary care by reduced length of stay. Additional factors that lead to current rising rates of hospital admission may include the use of general practitioner on-call deputising and NHS Direct telephone services meaning patients are unlikely to be initially assessed in the community by a doctor who knows them.

Intermediate care and older people.

Some IC services may also be subject to design flaws. For example, they may not be able to be accessed out of office hours at the time that an acute illness occurs.

To date, implementation has been patchy and not accurately powered in each region to produce a specified effect. Their staffing may draw experienced people away from their previous job within the NHS eg district nursing , without equivalent replacement. The gold standard of care for older adults with an acute illness is the acute geriatric unit within an acute hospital.

A recent metaanalysis found that specialist geriatric units offering multidisciplinary assessment were associated with a lower risk of functional decline by the time of discharge combined odds ratio 0. Exactly what this entails may vary. In overcrowded hospitals older patients may be cared for in non-specialist areas. As such it is unclear if IC has been compared to known best practice within every study. Intermediate care services are unlikely to meet the needs of all. Functional outcomes, institutionalisation rates and mortality were similar between groups. In conclusion, the evidence to support a move towards any form of IC service is still weak, even after 10 years of implementation.

There are no reliable data that suggest acute hospital use will be reduced, and costs could even be increased. Bearing this in mind, should the NHS be investing in such new services that may benefit a small proportion of older patients, or should it continue investing in the more traditional system that has been shown to benefit all? This question is particularly relevant when entering an economic phase where NHS expenditure is likely to be reduced and health choices need to be made.

User Name Password Sign In. Previous Section Next Section. In this window In a new window. Change in hospital use over time in England. Hospital at Home Hospital at Home HaH means the provision of healthcare within patients' own homes in a way similar to the services available within a hospital environment, ie in the absence of this service they would need to be admitted. Case management Case managers are people who help to coordinate and manage care for people with complex chronic conditions.

Paramedic assessment service As an alternative approach to admission avoidance, it has been proposed that ambulance crews could be trained to deliver treatment of minor conditions in the community in response to emergency calls. Hospital at Home A recent Cochrane review identified 26 trials involving the use of an HaH scheme to facilitate early discharge from hospital. Nurse-led units A trial randomised hospital inpatients mean age Community hospitals A trial randomised patients median age 86 years to a period of post-acute care within a community hospital or continuing standard care in an acute hospital.

Care homes Care home beds have been utilised as transitional units for patients whose discharge has been delayed due to awaiting a permanent care home place. What is intermediate care? An international consensus on what constitutes intermediate care is needed. BMJ ; The organisation, form and function of intermediate care services and systems in England: Health Soc Care Community ; CrossRef Medline Google Scholar. Department of Health , Better health in old age.

Hospital Episode Statistics , www. Rising to the challenge: Policy on the rebound: J R Soc Med ; An estimate of post-acute intermediate care need in an elderly care department for older people. Admission avoidance hospital at home. Cochrane Database Syst Rev ; 4: Randomised controlled trial of effectiveness of Leicester hospital at home scheme compared with hospital care. Economic evaluation of hospital at home versus hospital care: Patient and carer satisfaction with [Hospital at Home]: Br J Gen Practice ; Hospital in the home: Med J Australia ; The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: J Health Services Res Policy ; The effect of Evercare on hospital use.

J Am Geriatr Soc ; Department of Health , Case management competences framework for the care of people with long term conditions.

Supplemental Content

Department of Health , Supporting people with long term conditions: Follow up of people aged 65 and over with a history of emergency admissions: An evaluation of a community matron service from the patients' perspective. Br J Community Nurs ; Evaluation of community matron services in a large metropolitan city in England. Qual Prim Care ; Impact of case management Evercare on frail elderly patients: Department of Health , Taking healthcare to the patient: Effectiveness of paramedic practitioners in attending calls from elderly people in the community: This probably results from the existence of intermediate care facilities in the United States and Japan, which closely resemble nursing homes.

Further difficulty arises because individual authors also use the term intermediate care when describing a less advanced type of intensive care medicine. This inventory of definitions shows that the term intermediate care currently does not present imply a specific, well defined type of health care box.

This worrying conclusion has important consequences. To compare results of research projects will be difficult if not impossible, as will be identifying gaps in our current knowledge or critically appraising the benefits attributed to intermediate care.

A new service in the intermediate care of older adults with mental health problems.

These difficulties will only increase because of the growing popularity of alternatives to hospital inpatient care across Europe and the rest of the world. British Geriatrics Society 1. Medical subject heading MeSH 9. To deal with this Babel of voices we suggest a formal process to develop a consensus of the key elements of intermediate care. The aim of this debate should not be to arrive at a uniform definition of intermediate care, for our inventory on the definitions of intermediate care has shown that it is impossible to define intermediate care unequivocally at the highest conceptual level.

For reasons of simplicity, this debate should be limited to defining intermediate care for the purpose of scientific appraisal. It would also be helpful if bibliographers were able to establish a consensus for terminology, such as medical subheadings. If we do not clearly define key elements of the concept of intermediate care, then it will remain a concept with unfulfilled promise. National Center for Biotechnology Information , U. Journal List BMJ v. This article has been cited by other articles in PMC.

Definitions of intermediate care British Geriatrics Society 1 An approach to health care intended to facilitate patients' transitions from illness to recovery, or to prevent their transition from home managed chronic impairment to institution-based dependence, or to help terminally ill people be as comfortable as possible at the end of their lives. That range of services designed to facilitate transition from hospital to home, and from medical dependence to functional independence, where the objectives of care are not primarily medical, the patients' discharge destination is anticipated, and a clinical outcome of recovery or restoration of health is desired.

Lorna Dunipace, GHSCP - Glasgow Integrated Care for Older People – Intermediate Care

Those services that do not require the resources of a general hospital, but are beyond the scope of the traditional primary care team. The last definition is the same as the one the Royal College of Physicians uses in its statement 2. Intermediate care see subacute care is care provided to acute care patients who are medically stable but too unstable to be treated in alternative healthcare settings such as home, ambulatory, or traditional skilled long term care.

For care given in a nursing home, see long term care. Guidance for commissioners and providers of health and social care. BGS compendium document D4. British Geriatrics Society,