Impact of 'Enhanced' Intermediate Care Integrating Acute, Primary and Community Care and the Voluntary Sector in Torbay and South Devon, UK

Abstract

Introduction: Intermediate care (IC) was redesigned to manage more complex, older patients in the community, avoid admissions and facilitate earlier hospital discharge. The service was 'enhanced' by employing GPs, pharmacists and the voluntary sector to be part of a daily interdisciplinary team meeting, working alongside social workers and community staff (the traditional model).

Methods: A controlled before-and-after study, using mixed methods and a nested case study. Enhanced IC in one locality (Coastal) is compared with four other localities where IC was not enhanced until the following year (controls), using system-wide performance data (N = 4,048) together with ad hoc data collected on referral-type, staff inputs and patient experience (N = 72).

Results: Coastal showed statistically significant increase in EIC referrals to 11.6% (95%CI: 10.8%-12.4%), with a growing proportion from GPs (2.9%, 95%CI: 2.5%-3.3%); more people being cared for at home (10.5%, 95%CI: 9.8%-11.2%), shorter episode lengths (9.0 days, CI 95%: 7.6-10.4 days) and lower bed-day rates in ≥70 year-olds (0.17, 95%CI: 0.179-0.161). The nested case study showed medical, pharmacist and voluntary sector input into cases, a more holistic, coordinated service focused on patient priorities and reduced acute hospital admissions (5.5%).

Discussion and conclusion: Enhancing IC through greater acute, primary care and voluntary sector integration can lead to more complex, older patients being managed in the community, with modest impacts on service efficiency, system activity, and notional costs off-set by perceived benefits.

Keywords: admission avoidance; early supported discharge; intermediate care; multi-disciplinary teams; person-centred care; voluntary sector.

Figure 1

Data collection and time frames.

Figure 2

Intermediate care referral pathways, including the ‘enhanced’ pathway in Coastal locality. Key: The enhanced elements of IC are marked in bold, brown text and new pathways shown with dotted lines. The solid lines are pathways that are present in both EIC and IC. ED is emergency department. * South Devon localities also receive referrals from social care’s single point of contact (SPOC) service. Torbay localities have a combined health and social care SPOC.

Figure 3

Trends in bed-day rates for intermediate care beds, community and acute hospital beds for ≥70 year-olds by locality between 2015 and 2017. Key: ☆ = p ≥ 0.05 compared to other localities within year.

Figure 4

Patient experience questionnaire (P3C-EQ, N = 17), Coastal locality.

Figure 5

Perceived prevented impact of enhanced intermediate care and associated costs (annualised) in Coastal locality.