The role of community providers in supporting people with frailty
Tameside and Glossop Integrated Care NHS Foundation Trust
In December 2022, Tameside and Glossop Integrated Care NHS Foundation Trust set up a Frailty Same Emergency Care Unit in Tameside Hospital. The unit was established with the aim of providing comprehensive assessment and care for acutely unwell patients who are 65 and over. All patients are now screened each day for frailty, and those who need it are quickly transferred for a comprehensive assessment and treatment. Where appropriate, same day community discharge is arranged to avoid an unnecessary hospital admission.
From the minute this team took over the experience felt so different. My mum got expert care and was involved all the way through. The reason this experience was so important was that it meant her last days were spent with a team who really cared for her, and we couldn't have asked for more support.
Tameside and Glossop Integrated Care NHS Foundation Trust
The staff and doctors were outstanding in their attention to detail and high level of communication.
Tameside and Glossop Integrated Care NHS Foundation Trust
Very thorough ward and services, lovely caring and kind staff. Much needed holistic approach.
Tameside and Glossop Integrated Care NHS Foundation Trust
Intermediate care
Intermediate care is particularly important for people living with frailty. This type of support can help people with frailty access additional support on a time limited basis to prevent an unnecessary hospital admission, as well as help people to regain their independence and support them to recover at home after a hospital stay, in turn reducing the risk of readmission to hospital, and reducing pressures on hospital capacity.
To date, national policy has focused on how intermediate care can support people after a hospital stay, otherwise known as 'step-down' care.
According to NHS England's intermediate care framework (published in September 2023), step-down intermediate care is 'time-limited, short-term health and/or social care provided to adults who need support after discharge from acute inpatient settings and virtual wards to help them rehabilitate, re-able and recover'. Care is often delivered by a multi-disciplinary team made up of health and social care staff working in integrated ways to deliver more holistic, wraparound care for the benefit of patients. Alongside key partners across the health and care system, community providers have a vital role to play in delivering these services.
Coventry and Warickshire ICS
Health and social care partners across Warwickshire have been working together to improve timely access to therapeutic intermediate care services upon discharge from hospital through the establishment of a Community Recovery Service. The service commenced in April 2023 and allows more people to access rehabilitation and recovery services after a hospital stay, with the aim of reducing length of stay in acute hospitals and maximising the home first approach. The package of intermediate care is provided and paid for by the NHS (via the Better Care Fund) for up to six weeks, with individuals being encouraged to maximise the use of this time to reduce the need for further care.
As part of this programme, all patients who no longer fit the criteria to reside in hospital and are assessed as pathway 1 (this applies to someone who is ready to be discharged to a usual place of residence or temporary accommodation with some form of health and/or care and support needs), are triaged by the therapy team to decide if they need ongoing therapeutic intervention alongside a domiciliary care package. Care is delivered at a person's home by the Community Recovery Service which is made up of domiciliary care workers and allied health professionals from South Warwickshire University NHS Foundation Trust.
Walsall Healthcare NHS Trust
Walsall Healthcare NHS Trust has a well-established intermediate care service delivered by a multi-disciplinary team across Walsall Healthcare NHS Trust and Walsall adult social care. The service provides short-term, intensive support to patients to help them leave hospital as soon as it is safe to do so. The team, which is made up of a range of health and care professionals, offers support to help patients regain their independence, either at home or in a short-stay care home bed, in a way that best suits their needs.