Community Crisis and Recovery Services

Approach

Access to community crisis and recovery services (with active recuperation, rehabilitation and reablement) including frailty-focused transport with timely transfers of care from hospital, involving carers and families.

Intermediate care is a range of integrated services that offer crisis response to prevent hospital admission, safe and timely discharge from hospital as well as promoting robust recovery, recuperation and rehabilitation.

There are 3 main aims:

  • Help people avoid going into (or remaining in) hospital unnecessarily;
  • Help people be as independent as possible after a stay in hospital; and
  • Prevent people from having to move into a care home until they really need to.

Generally, services are categorised into bed-based and home-based services.

The following are examples of what to  consider when thinking about creating a responsive system outside of hospital that supports crisis intervention, recovery and recuperation. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/making-health-care-systems-fit-ageing-population-oliver-foot-humphries-mar14.pdf

  • Continuity of primary care with same day access.
  • Co-ordinated social care.
  • Adequate and flexible provision of step-up and step-down home-based and bed-based rehabilitation and re-ablement services
  • Single point of access available to facilitate access to community services to manage crisis at home with specialist opinion and diagnostics – including virtual/community wards and telecare.
  • Ambulatory emergency pathways with access to multi-disciplinary teams should be available in less than 4 hours.
  • Mental health services should contribute with specialist mental health assessments if appropriate.
  • Specialist support through physiotherapy, occupational therapy, speech and language and dietetics should be readily available.
  • An interface or community geriatrician service is available to provide expert clinical opinion.
  • A personalised care plan ideally including (if appropriate) an emergency contingency plan, advanced care plan and ‘allow a natural death’ order documentation. The care plan should ideally include known baselines, physical and mental health and functional status.
  • There are shared care protocols with ambulance organisations that can enable older people to remain at home.
  • There is a hospital based multi-disciplinary team located at the front door of the hospital integrated with the community team and focused on the facilitation of discharge.
  • Early senior assessment, assertive discharge planning, and a clear focus on patient flow.
  • Discharge to an older person’s normal residence should be possible within 24 hours, seven days a week.
  • Older people being admitted following an urgent care episode should have an expected discharge date set within two hours.
  • Care packages to support discharge should be available within 24 hours of referral to Adult Care and Support.
  • Adequate and timely information must be shared between services whenever there is a transfer of care between individuals or services.
  • When preparing for discharge, older people and carers should be offered details of local voluntary sector organisations.
  • Voluntary sector services should be available to provide a ‘welcome home’ 7 days a week.
  • Strengthening post-discharge assessment and support.
  • Rapid access to housing adaptations and aids.

Resources

Evidence

  • The National Intermediate Care audit summary report (2015) states that the ‘outcome evidence’ for intermediate care is multifaceted.  In terms of likelihood of returning home, improvement in activities of daily living, achievement of person specific goals, or structured assessment of care experience (PREMs) – all point to intermediate care doing its job of promoting and sustaining the desirable outcome of functional independence.  In addition, about two thirds of the service users replied that their social contacts had been definitely or to some extent improved helping them with their loneliness
  • Hospital at home schemes that include multidisciplinary care and medical input can be effective and could support A&E based teams in reducing the need to access A&E.

Nutrition and Hydration

XXXXXXX

Bowel and bladder care

XXXXXXX

Sight and hearing

XXXXXXX

Cognition and Dementia Care

XXXXXXX

End of Life Care

XXXXXXX

Local stories

LINKS

Top Tips on ‘delivery and implementation’

XXXXXXXXXX

Top Tips on ‘workforce, skills and training’

XXXXXXXXXX