Recommendations | Intermediate care including reablement | Guidance

1.1 Core principles of intermediate care, including reablement

1.1.1

Ensure that intermediate care practitioners:

develop goals in a collaborative way that optimises independence and wellbeing
adopt a person-centred approach, taking into account cultural differences and preferences.

1.1.2

At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and:

other agencies
people using the service and their families and carers.

1.1.3

Intermediate care practitioners should:

work in partnership with the person to find out what they want to achieve and understand what motivates them
focus on the person's own strengths and help them realise their potential to regain independence
build the person's knowledge, skills, resilience and confidence
learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack
support positive risk taking.

1.1.4

Ensure that the person using intermediate care and their family and carers know who to speak to if they have any questions or concerns about the service, and how to contact them.

1.1.5

Offer the person the information they need to make decisions about their care and support, and to get the most out of the intermediate care service. Offer this information in a range of accessible formats, for example:

verbally
in written format (in plain English)
in other accessible formats, such as braille or Easy Read
translated into other languages
provided by a trained, qualified interpreter.

1.2 Supporting infrastructure

1.2.1

Consider making home-based intermediate care, reablement, bed-based intermediate care and crisis response all available locally. Deliver these services in an integrated way so that people can move easily between them, depending on their changing support needs.

1.2.2

Ensure that intermediate care is provided in an integrated way by working towards the following:

a single point of access for those referring to the service
a management structure across all services that includes a single accountable person, such as a team leader
a single assessment process
a shared understanding of what intermediate care aims to do
an agreed approach to outcome measurement for reporting and benchmarking.

1.2.3

Contract and monitor intermediate care in a way that allows services to be flexible and person centred. For recommendations on delivering flexible services, see NICE's guideline on home care.

1.2.4

Ensure that intermediate care teams work proactively with practitioners referring into the service so they understand:

the service and what it involves
how it differs from other services
the ethos of intermediate care, specifically that it aims to support people to build independence and improve their quality of life
that intermediate care is free for the period of delivery.

1.2.5

Ensure that mechanisms are in place to promote good communication within intermediate care teams. These might include:

regular team meetings to share feedback and review progress
shared notes
opportunities for team members to express their views and concerns.

1.2.6

Ensure that the intermediate care team has a clear route of referral to and engagement with commonly used services, for example:

general practice
podiatry
pharmacy
mental health and dementia services
specialist and longer-term rehabilitation services
housing services
voluntary, community and faith services
specialist advice, for example around cultural or language issues.

1.2.7

Consider deploying staff flexibly across intermediate care, where possible following the person from hospital to a community bed‑based service or directly to their home.

1.2.8

Ensure that the composition of intermediate care teams reflects the different needs and circumstances of people using the service.

1.2.9

Ensure that intermediate care teams include a broad range of disciplines. The core team should include practitioners with skills and competences in the following:

delivering intermediate care packages
nursing
social work
therapies, for example occupational therapy, physiotherapy and speech and language therapy
comprehensive geriatric assessment.

1.3 Assessment of need for intermediate care

This section relates to the assessment of a person's support needs. It could be undertaken by a range of professionals, for example therapists, nursing staff or social workers, working in various locations. It aims to ensure that the type of intermediate care support is appropriate for the person's needs and circumstances.

1.3.1

Assess people for intermediate care if it is likely that specific support and rehabilitation would improve their ability to live independently and they:

are at risk of hospital admission or have been in hospital and need help to regain independence or
are living at home and having increasing difficulty with daily life through illness or disability.

1.3.2

Do not exclude people from intermediate care based on whether they have a particular condition, such as dementia, or live in particular circumstances, such as prison, residential care or temporary accommodation.

1.3.3

During assessment identify the person's abilities, needs and wishes so that they can be referred for the most appropriate support.

1.3.4

Actively involve people using services (and their families and carers, as appropriate) in assessments for intermediate care and in decisions such as the setting in which it is provided.

1.3.5

When assessing people for intermediate care, explain to them (and their families and carers, as appropriate) about advocacy services and how to contact them if they wish.

1.4 Referral into intermediate care

People may be referred into the services described in this section by either health or social care practitioners. The location of intermediate care will vary depending on how different areas configure the service to meet local circumstances and needs. Intermediate care could be commissioned by either health or social care commissioners, or jointly as part of an integrated working approach.

1.4.1

Consider providing intermediate care to people in their own homes wherever practical, making any adjustments, for example equipment or adaptations, needed to enable this to happen.

1.4.2

Offer reablement as a first option to people being considered for home care, if it has been assessed that reablement could improve their independence.

1.4.3

For people already using home care, consider reablement as part of the review or reassessment process. Be aware that this may mean providing reablement alongside home care. Take into account the person's needs and preferences when considering reablement and work closely with the home care provider.

1.4.4

Consider reablement for people living with dementia, to support them to maintain and improve their independence and wellbeing.

1.4.5

Consider bed-based intermediate care for people who are in an acute but stable condition but not fit for safe transfer home. Be aware that if the move to bed-based intermediate care takes longer than 2 days it is likely to be less successful.

1.4.6

Refer people to crisis response if they have experienced an urgent increase in health or social care needs and:

the cause of the deterioration has been identified
their support can be safely managed in their own home or care home
the need for more detailed medical assessments has been addressed.

1.4.7

The crisis response service should raise awareness of its purpose and function among other local services such as housing and the voluntary sector. This means making sure they understand:

the service and what it involves
how it differs from other types of intermediate care
how to refer to the service.

1.5 Entering intermediate care

1.5.1

Discuss with the person the aims and objectives of intermediate care and record these discussions. In particular, explain clearly:

that intermediate care is designed to support them to live more independently, achieve their own goals and have a better quality of life
that intermediate care works with existing support networks, including friends, family and carers
how working closely together and taking an active part in their support can produce the best outcomes.

1.5.2

When a person starts using intermediate care, give their family and carers:

information about the service's aims, how it works and the support it will and will not provide
information about resources in the local community that can support them
opportunities to express their wishes and preferences, alongside those of the person using the service
opportunities to ask questions about the service and what it involves.

1.5.3

For bed-based intermediate care, start the service within 2 days of receiving an appropriate referral. Be aware that delays in starting intermediate care increase the risk of further deterioration and reduced independence.

Crisis response

1.5.4

Ensure that the crisis response can be started within 2 hours from receipt of a referral when necessary.

1.5.5

As part of the assessment process, ensure that crisis response services identify the person's ongoing support needs and make arrangements for the person's ongoing support.

1.5.6

Establish close links between crisis response and diagnostics (for example, GP, X‑ray or blood tests) so that people can be diagnosed quickly if needed.

Person-centred planning

1.5.7

When planning the person's intermediate care:

assess and promote the person's ability to self-manage
tell the person what will be involved
be aware that the person needs to give consent for their information to be shared
tell the person that intermediate care is a short-term service and explain what is likely to happen afterwards.

1.5.8

Carry out a risk assessment as part of planning for intermediate care and then regularly afterwards, as well as when something significant changes. This should include:

assessing the risks associated with the person carrying out particular activities, including taking and looking after their own medicines
assessing the risks associated with their environment
balancing the risk of a particular activity with the person's wishes, wellbeing, independence and quality of life.

For recommendations on supporting people in residential care to take and look after their medicines themselves, see NICE's guidelines on managing medicines in care homes and medicines optimisation.

[This recommendation is adapted from NICE's guideline on home care]

1.5.9

Complete and document a risk plan with the person (and their family and carers, as appropriate) as part of the intermediate care planning process. Ensure that the risk plan includes:

strategies to manage risk; for example, specialist equipment, use of verbal prompts and use of support from others
the implications of taking the risk for the person and the member of staff.

[This recommendation is adapted from NICE's guideline on home care]

Agreeing goals

1.5.10

Discuss and agree intermediate care goals with the person. Make sure these goals:

are based on specific and measurable outcomes
take into account the person's health and wellbeing
reflect what the intermediate care service is designed to achieve
reflect what the person wants to achieve both during the period in intermediate care, and in the longer term
take into account how the person is affected by their conditions or experiences
take into account the best interests and expressed wishes of the person.

1.5.11

Recognise that participation in social and leisure activities are legitimate goals of intermediate care.

1.5.12

Document the intermediate care goals in an accessible format and give a copy to the person, and to their family and carers if the person agrees to this.

1.6 Delivering intermediate care

1.6.1

Take a flexible, outcomes-focused approach to delivering intermediate care that is tailored to the person's social, emotional and cognitive and communication needs and abilities.

1.6.2

Review people's goals with them regularly. Adjust the period of intermediate care depending on the progress people are making towards their goals.

1.6.3

Ensure that staff across organisations work together to coordinate review and reassessment, building on current assessment and information. Develop integrated ways of working, for example, joint meetings and training and multidisciplinary team working.

1.6.4

Ensure that specialist support is available to people who need it (for example, in response to complex health conditions), either by training intermediate care staff or by working with specialist organisations. [This recommendation is adapted from NICE's guideline on home care]

1.6.5

Ensure that an intermediate care diary (or record) is completed and kept with the person. This should:

provide a detailed day-to-day log of all the support given, documenting the person's progress towards goals and highlighting their needs, preferences and experiences
be updated by intermediate care staff at every visit
be accessible to the person themselves, who should be encouraged to read and contribute to it
keep the person (and their family and carers, as appropriate) and other staff fully informed about what has been provided and about any incidents or changes.

1.6.6

Ensure that intermediate care staff avoid missing visits to people's homes. Be aware that missing visits can have serious implications for the person's health or wellbeing, particularly if they live alone or lack mental capacity. [This recommendation is adapted from NICE's guideline on home care]

1.6.7

Contact the person (or their family or carer) if intermediate care staff are going to be late or unable to visit. [This recommendation is adapted from NICE's guideline on home care]

1.7 Transition from intermediate care

1.7.1

Before the person finishes intermediate care, providers of intermediate care should give them information about how they can refer themselves back into the service, should their needs or circumstances change.

1.7.2

Ensure good communication between intermediate care staff and other agencies. There should be a clear plan for when people transfer between services, or when the intermediate care service ends. This should:

be documented and agreed with the person and their family or carers
include contact details for the service
include a contingency plan should anything go wrong.

For recommendations on communication during transition between services, see NICE's guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs.

1.7.3

Give people information about other sources of support available at the end of intermediate care, including support for carers.

1.8 Training and development

1.8.1

Ensure that all staff delivering intermediate care understand:

the service and what it involves
the roles and responsibilities of all team members
how it differs from other services
the ethos of intermediate care, specifically that it aims to support people to build independence
how to work collaboratively with people to agree person-centred goals
positive risk taking.

1.8.2

Ensure that intermediate care staff are able to recognise and respond to:

common conditions, such as diabetes; mental health and neurological conditions, including dementia; frailty; stroke; physical and learning disabilities; sensory loss; and multi-morbidity
common support needs, such as nutrition, hydration, continence, and issues related to overall skin integrity
common support needs, such as dealing with bereavement and end of life
deterioration in the person's health or circumstances.

[This recommendation is adapted from NICE's guideline on home care]

1.8.3

Provide intermediate care staff with opportunities for:

observing the work of another member of staff
enhancing their knowledge and skills in relation to delivering intermediate care
reflecting on their practice together.

Document these development activities and record that people have achieved the required level of competence.

1.8.4

Ensure that intermediate care staff have the skills to support people to:

optimise recovery
take control of their lives
regain as much independence as possible.

Terms used in this guideline

Bed-based intermediate care

Assessment and interventions provided in a bed-based setting, such as an acute hospital, community hospital, residential care home, nursing home, stand-alone intermediate care facility, independent sector facility, local authority facility or other bed-based setting. Bed-based intermediate care aims to prevent unnecessary admissions to acute hospitals and premature admissions to long-term care, and to support timely discharge from hospital. For most people, interventions last up to 6 weeks. Services are usually delivered by a multidisciplinary team but most commonly by healthcare professionals or care staff (in care homes).

Crisis response

Community-based services provided to people in their own home or a care home. These services aim to avoid hospital admissions. Crisis response usually involves an assessment, and may provide short-term interventions (usually up to 48 hours). Crisis response is delivered by a multidisciplinary team but most commonly by healthcare professionals.

Home-based intermediate care

Community-based services that provide assessment and interventions to people in their own home or a care home. These services aim to prevent hospital admissions, support faster recovery from illness, support timely discharge from hospital, and maximise independent living. For most people interventions last up to 6 weeks. Services are delivered by a multidisciplinary team but most commonly by healthcare professionals or care staff (in care homes).

Home care

Care provided in a person's own home by paid care workers which helps them with their daily life. It is also known as domiciliary care. Home care workers are usually employed by an independent agency, and the service may be arranged by the local council or by the person receiving home care (or someone acting on their behalf).

Intermediate care

A range of integrated services that: promote faster recovery from illness; prevent unnecessary acute hospital admissions and premature admissions to long-term care; support timely discharge from hospital; and maximise independent living. Intermediate care services are usually delivered for no longer than 6 weeks and often for as little as 1 to 2 weeks. Four service models of intermediate care are available: bed-based intermediate care, crisis response, home-based intermediate care, and reablement.

Person-centred approach

An approach that puts the person at the centre of their support and goal planning. It is based around the person's strengths, needs, preferences and priorities. It involves treating them as an equal partner and considering whether they may benefit from intermediate care, regardless of their living arrangements, socioeconomic status or health conditions.

Positive risk taking

This involves balancing the positive benefits gained from taking risks against the negative effects of attempting to avoid risk altogether.

Reablement

Assessment and interventions provided to people in their home (or care home) aiming to help them recover skills and confidence and maximise their independence. For most people interventions last up to 6 weeks. Reablement is delivered by a multidisciplinary team but most commonly by social care practitioners.

For other social care terms see the Think Local, Act Personal Care and Support Jargon Buster.