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Intermediate care including reablement

About

What is covered

This interactive flowchart covers referral and assessment for, and delivery of intermediate care, which uses a range of multidisciplinary service models to help people be as independent as possible and to improve their wellbeing. It covers how to support people at risk of hospital admission or who have been in hospital, to help them recover and regain independence.

Updates

Updates to this interactive flowchart

8 August 2018 Intermediate care including reablement (NICE quality standard 173) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on referral and assessment for and delivery of intermediate care including reablement in an interactive flowchart

What is covered

This interactive flowchart covers referral and assessment for, and delivery of intermediate care, which uses a range of multidisciplinary service models to help people be as independent as possible and to improve their wellbeing. It covers how to support people at risk of hospital admission or who have been in hospital, to help them recover and regain independence.

Updates

Updates to this interactive flowchart

8 August 2018 Intermediate care including reablement (NICE quality standard 173) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Intermediate care including reablement (2017) NICE guideline NG74
Intermediate care including reablement (2018) NICE quality standard 173

Quality standards

Intermediate care including reablement

These quality statements are taken from the intermediate care including reablement quality standard. The quality standard defines clinical best practice for intermediate care including reablement and should be read in full.

Quality statements

Discussion about intermediate care

This quality statement is taken from the intermediate care including reablement quality standard. The quality standard defines clinical best practice for intermediate care including reablement and should be read in full.

Quality statement

Adults being assessed for intermediate care have a discussion about the support the service will and will not provide.

Rationale

Healthcare professionals in hospitals or the community who are assessing people for intermediate care should have a discussion, provide information and ensure that the person (and their family and carers, as appropriate) understand what intermediate care is and what it can and cannot achieve. This will ensure that people are involved in making decisions about their care and encouraged to engage with the rehabilitation process. It will also enable them to consider any further support they may need in addition to intermediate care.

Quality measures

Structure
a) Evidence that information about the support provided by the local intermediate care service is available.
Data source: Local data collection, for example, leaflets or booklets or pamphlets tailored to local services.
b) Evidence of local processes to ensure that adults being assessed for intermediate care have a discussion about the support the service will and will not provide.
Data source: Local data collection, for example, service protocol.
Process
Proportion of adults being assessed for intermediate care who have a record of a discussion about the support the service will and will not provide.
Numerator – the number in the denominator who have a record of a discussion about the support the service will and will not provide.
Denominator – the number of adults being assessed for intermediate care.
Data source: Local data collection, for example, audit of electronic records.
Outcome
Level of awareness of the support the service provides among adults assessed for intermediate care and their families and carers.
Data source: Local data collection, for example, survey of adults assessed for intermediate care and their families and carers.

What the quality statement means for different audiences

Service providers (such as hospitals, community providers, local authorities, care homes, home care agencies and not-for-profit social enterprises) ensure that staff carrying out assessments for intermediate care have the knowledge and materials to provide information and have a discussion with the person (and their family and carers, as appropriate) about the support the service will and will not provide. Service providers ensure that processes are in place for staff to record that the discussion took place.
Health and social care practitioners (such as nurses, discharge coordinators, trusted assessors, social workers and allied health professionals) ensure that, when they carry out an assessment for intermediate care, they give up-to-date information and have a discussion with the person (and their family and carers, as appropriate) about the support the service will and will not provide. They should provide information in a suitable format to meet individual needs and record that the discussion took place.
Commissioners (such as clinical commissioning groups and local authorities) ensure that services assessing adults for intermediate care have processes in place for staff to give information and have a discussion with the person (and their family and carers as appropriate) about the support the service will and will not provide. Commissioners should ensure that information is available about the full range of local intermediate care services, so that people know what options they have.
Adults being assessed for intermediate care discuss with their care team the type of support the service will and will not provide. Their family and carers should be involved if appropriate. Clear information (such as a leaflet or booklet) should be provided about what care is available. This discussion will help the person to make decisions about their care and to work with the intermediate care service to gain as much benefit from the service as possible.

Source guidance

Intermediate care including reablement (2017) NICE guideline NG74, recommendations 1.1.5, 1.5.1 and 1.5.2

Definitions of terms used in this quality statement

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
  • 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
  • reablement.
[NICE’s guideline on intermediate care including reablement, terms used in this guideline section]
Discussion about the support the service will and will not provide
The discussion should include:
  • the aims and objectives of intermediate care, in particular, that it is designed to support them to live more independently, achieve their own goals and have a better quality of life
  • any options for intermediate care services in different settings locally
  • how the intermediate care service works and the support it will and will not provide
  • information about other resources in the local community that can provide support
  • how to get further information.
[NICE’s guideline on intermediate care including reablement, recommendations 1.3.4, 1.5.1 and 1.5.2]

Equality and diversity considerations

Service providers should 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.
Discussions about the support provided by intermediate care may need to be adapted to meet the needs of people living with cognitive impairment, including dementia, and their family and carers. Healthcare professionals should ensure that the person living with cognitive impairment is supported by a relative or carer or an advocate (as appropriate) to ensure involvement in the discussion.

Starting bed-based intermediate care

This quality statement is taken from the intermediate care including reablement quality standard. The quality standard defines clinical best practice for intermediate care including reablement and should be read in full.

Quality statement

Adults accepted for bed-based intermediate care start the service within 2 days of referral.

Rationale

Delays in starting bed-based intermediate care can increase the risk of further deterioration in the person’s condition and lead to reduced independence. If the move to bed-based intermediate care from hospital or the community takes longer than 2 days it is likely to be less successful and could lead to admissions to hospital or residential care that could have been avoided.

Quality measures

Structure
Evidence of local arrangements to ensure that bed-based intermediate care can be started within 2 days of referral.
Data source: Local data collection, for example, referral pathways from hospital and the community and service protocols.
Process
a) Proportion of adults accepted for bed-based intermediate care from hospital who start the service within 2 days of referral.
Numerator – the number in the denominator who start the service within 2 days of referral.
Denominator – the number of adults accepted for bed-based intermediate care from hospital.
Data source: Local data collection, for example, audit of electronic records. The NHS Benchmarking Network National Audit of Intermediate Care includes data on waiting times for bed-based intermediate care.
b) Proportion of adults accepted for bed-based intermediate care from the community who start the service within 2 days of referral.
Numerator – the number in the denominator who start the service within 2 days of referral.
Denominator – the number of adults accepted for bed-based intermediate care from the community.
Data source: Local data collection, for example, audit of electronic records. The NHS Benchmarking Network National Audit of Intermediate Care includes data on waiting times for bed-based intermediate care.
c) Proportion of referrals for bed-based intermediate care that were not accepted due to insufficient capacity.
Numerator – the number in the denominator that were not accepted due to insufficient capacity.
Denominator – the number of referrals for bed-based intermediate care.
Data source: Local data collection, for example, audit of referral records. The NHS Benchmarking Network National Audit of Intermediate Care includes data on reasons for not being accepted onto the scheme including a lack of capacity.
Outcome
a) Rate of unplanned hospital admissions for chronic ambulatory care sensitive conditions.
Data source: Data on unplanned hospital admissions for chronic ambulatory care sensitive conditions are available from NHS Digital’s Clinical Indicators as part of the NHS outcomes framework – indicator 2.3i.
b) Rate of delayed transfer of care from hospital for adults.
Data source: Data on average number of delayed transfers of care from hospital per 100,000 population are available from NHS Digital’s Clinical Indicators as part of the adult social care outcomes framework – indicator 2c.
c) Proportion of discharges from bed-based intermediate care to acute hospital or residential care.
Data source: Local data collection, for example, audit of electronic records. The NHS Benchmarking Network National Audit of Intermediate Care includes destination on discharge for adults admitted to bed-based intermediate care.
d) Proportion of people who were still at home 91 days after discharge from hospital into reablement or rehabilitation services.
Data source: Local data collection, for example, audit of case records. Data on the proportion of older people (aged 65 and over) who, after a period of reablement or rehabilitation, maintain their independence by remaining or returning to their home or previous residence 91 days after leaving hospital are available from NHS Digital’s Clinical Indicators as part of the NHS outcomes framework – indicator 3.6.i.

What the quality statement means for different audiences

Service providers (such as hospitals, community providers, care homes and not-for-profit social enterprises) have processes in place to ensure that adults start bed-based intermediate care within 2 days of referral from hospital or the community. This may require a coordinated approach to manage demand for intermediate care across local hospital and intermediate care services, for example, through a single point of access for referrals.
Health and social care practitioners (such as nurses and allied health professionals) ensure that adults accepted for bed-based intermediate care start the service within 2 days of referral from hospital or the community.
Commissioners (such as clinical commissioning groups and local authorities) commission bed-based intermediate care services with sufficient capacity to ensure that adults can start the service within 2 days of referral from hospital or the community. Commissioners ensure that they manage demand for intermediate care services efficiently, for example, through a single point of access for referrals. Commissioners monitor waiting times for bed-based intermediate care.
Adults who are having bed-based intermediate care to help their recovery are able to start this within 2 days of being referred. This will help them to regain their independence as soon as possible.

Source guidance

Intermediate care including reablement (2017) NICE guideline NG74, recommendation 1.5.3.

Definitions of terms used in this quality statement

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. For most people, interventions last up to 6 weeks. Services are usually delivered by healthcare professionals or care staff (in care homes) as part of a multidisciplinary team.
[NICE’s guideline on intermediate care including reablement, terms used in this guideline section]
Within 2 days of referral
Within 48 hours of receipt of the referral.
[NICE’s guideline on intermediate care including reablement, recommendation 1.5.3]

Equality and diversity considerations

Providers of bed-based intermediate care should not exclude people based on whether they have a particular condition, such as dementia, or live in particular circumstances, such as prison, residential care or temporary accommodation.

Personalised goals

This quality statement is taken from the intermediate care including reablement quality standard. The quality standard defines clinical best practice for intermediate care including reablement and should be read in full.

Quality statement

Adults starting intermediate care discuss and agree personalised goals.

Rationale

Involving people in identifying and agreeing their goals for intermediate care will help to ensure that the care is person-centred and focused on their individual strengths and preferences. Setting personalised goals will also encourage the person to be engaged in their care and promote independence. Personalised goals should be reviewed regularly.

Quality measures

Structure
a) Evidence of local arrangements to ensure that staff carrying out assessments for intermediate care are trained to discuss and agree personalised goals with adults starting the service.
Data source: Local data collection, for example, competency assessments.
b) Evidence of local processes to ensure that personalised goals are documented and shared with the person starting intermediate care, their family and carers (as appropriate), and care staff.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of adults starting intermediate care who have a record of a discussion to agree personalised goals.
Numerator – the number in the denominator who have a record of a discussion to agree personalised goals.
Denominator – the number of adults starting intermediate care.
Data source: Local data collection, for example, audit of electronic records.
b) Proportion of adults starting intermediate care who have documented personalised goals.
Numerator – the number in the denominator who have documented personalised goals.
Denominator – the number of adults starting intermediate care.
Data source: Local data collection, for example, audit of care plans.
Outcome
a) Satisfaction of adults discharged from intermediate care that the service supported them to achieve their personalised goals.
Data source: Local data collection, for example, survey of adults discharged from intermediate care.
b) Proportion of adults discharged from intermediate care with a level of independence improved from admission.
Data source: Local data collection, for example, audit of electronic records. The NHS Benchmarking Network National Audit of Intermediate Care collects data on dependency levels based on the Modified Barthel Index for bed-based services and the Sunderland Community Scheme for home-based and reablement services.

What the quality statement means for different audiences

Service providers (such as hospitals, community providers, local authorities, care homes, home care agencies and not-for-profit social enterprises) ensure that processes are in place to discuss and agree personalised goals with adults starting intermediate care, and their family and carers as appropriate. Providers ensure that personalised goals are documented and shared with the person, their family and carers as appropriate, and staff providing care. Providers ensure that the care provided supports people to achieve their goals and that their personalised goals are reviewed regularly.
Health and social care practitioners (such as nurses, social workers, allied health professionals, and care staff) ensure that they discuss and agree personalised goals with adults starting intermediate care, and their family and carers as appropriate. They give a copy of the agreed personalised goals, in a suitable format, to the person, their family and carers as appropriate, and staff providing care. Health and social care practitioners ensure that personalised goals are reviewed regularly and that they provide care to support people to achieve their goals.
Commissioners (such as clinical commissioning groups and local authorities) commission intermediate care services that have processes in place to discuss, agree, document and share personalised goals for adults starting to use the service. Commissioners ensure that providers review personalised goals regularly and monitor whether goals are achieved, including levels of dependency, both at the start of the service and on discharge.
Adults starting intermediate care are supported by the care team to plan what they want to achieve – their personalised goals. They are given a copy of their agreed goals in a format that suits them. Agreeing clear goals will help them to work towards improving their independence. Their family and carers may also be involved. Personalised goals should be regularly reviewed.

Source guidance

Intermediate care including reablement (2017) NICE guideline NG74, recommendation 1.5.10

Definitions of terms used in this quality statement

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
  • 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
  • reablement.
[NICE’s guideline on intermediate care including reablement, terms used in this guideline section]
Personalised goals
Personalised goals to optimise independence and wellbeing should:
  • be 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.
[NICE’s guideline on intermediate care including reablement, recommendations 1.1.1 and 1.5.10]

Equality and diversity considerations

Individual cultural and religious needs should be taken into account when discussing and agreeing personalised goals for intermediate care.
Discussions about personalised goals for intermediate care may need to be adapted to meet the needs of people living with cognitive impairment, including dementia, and their family and carers. Healthcare professionals should ensure that the person living with cognitive impairment is supported by a relative or carer or an advocate as appropriate. 

Transition plan

This quality statement is taken from the intermediate care including reablement quality standard. The quality standard defines clinical best practice for intermediate care including reablement and should be read in full.

Quality statement

Adults using intermediate care services discuss and agree a transition plan for when their support ends.

Rationale

An agreed transition plan for when support from the intermediate care service ends will help to ensure that a person’s specific needs are met, transfers to other services are successful and the likelihood of hospital admission is reduced. Transition planning should begin as soon as a person starts using the intermediate care service. The transition plan should be reviewed before discharge to reflect any progress made.

Quality measures

Structure
a) Evidence of local referral pathways between intermediate care and statutory, independent and voluntary services.
Data source: Local data collection, for example, a directory of services that includes referral criteria and processes.
b) Evidence of local information about where adults leaving intermediate care can get support.
Data source: Local data collection, for example, a booklet or website with information about local services.
c) Evidence of local processes to ensure that adults using intermediate care services discuss and agree a transition plan for when their support ends.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of adults starting to use intermediate care services who have a record of a discussion to agree a transition plan for when their support ends.
Numerator – the number in the denominator who have a record of a discussion to agree a transition plan for when their support ends.
Denominator – the number of adults starting to use intermediate care services.
Data source: Local data collection, for example, audit of electronic records.
b) Proportion of adults starting to use intermediate care services who have a documented transition plan for when their support ends.
Numerator – the number in the denominator who have a documented transition plan for when their support ends.
Denominator – the number of adults starting to use intermediate care services.
Data source: Local data collection, for example, audit of electronic records.
c) Proportion of adults discharged from intermediate care whose transition plan for when their support ends was reviewed before discharge.
Numerator – the number in the denominator whose transition plan for when their support ends was reviewed before discharge.
Denominator – the number of adults discharged from intermediate care.
Data source: Local data collection, for example, audit of electronic records.
Outcome
a) Rate of emergency readmissions to hospital within 30 days of discharge from hospital into reablement or rehabilitation services.
Data source: Local data collection, for example, audit of case records. Data on all emergency readmissions within 30 days of discharge from hospital are available from NHS Digital’s Clinical Indicators as part of the clinical commissioning group outcomes indicator set – indicator 3.2.
b) Proportion of people who were still at home 91 days after discharge from hospital into reablement or rehabilitation services.
Data source: Local data collection, for example, audit of case records. Data on the proportion of older people (aged 65 and over) who, after a period of reablement or rehabilitation, maintain their independence by remaining or returning to their home or previous residence 91 days after leaving hospital are available from NHS Digital’s Clinical Indicators as part of the NHS outcomes framework – indicator 3.6.i.
c) Satisfaction of adults with their transition from intermediate care.
Data source: Local data collection, for example, survey of people discharged from intermediate care.

What the quality statement means for different audiences

Service providers (such as hospitals, community providers, local authorities, care homes, home care agencies and not-for-profit social enterprises ) ensure that processes are in place for adults starting to use intermediate care services, and their family and carers as appropriate, to be involved in developing and agreeing a clear transition plan for when their support ends. Providers ensure that staff are aware of local referral pathways to other statutory, independent and voluntary services, and can access information about local sources of support for adults leaving intermediate care. Providers ensure that the agreed transition plan is documented and shared with the person (and their family and carers as appropriate) and that it is reviewed before discharge to reflect any progress made.
Health and social care practitioners (such as nurses, social workers and allied health professionals) involve adults starting to use intermediate care services, and their family and carers as appropriate, in developing a transition plan for when their support ends. They ensure that the plan is agreed and documented. They provide a copy of the plan in a suitable format to the person (and their family and carers as appropriate) and review the plan before the person is discharged to reflect any progress made.
Commissioners (such as clinical commissioning groups and local authorities) ensure that specifications for intermediate care services include agreeing a clear transition plan with adults starting to use the service (and their family and carers as appropriate), documenting and sharing the plan, and reviewing the plan before discharge. Commissioners ensure that clear referral pathways are in place and there is information about local services that provide support after intermediate care ends.
Adults starting to use intermediate care services are involved in developing and agreeing a plan for any support they may need once their support ends. Their family and carers may also be involved if this is appropriate. The transition plan might include moving to another service, and should include information about other types of support available locally and how to ask for intermediate care in the future. The plan should be clear and easy to understand, and a copy should be given to the person. It should be checked before they are discharged to make sure it is still relevant. The transition plan should help to ensure that they can remain as independent as possible after intermediate care.

Source guidance

Intermediate care including reablement (2017) NICE guideline NG74, recommendation 1.7.2

Definitions of terms used in this quality statement

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
  • 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
  • reablement.
[NICE’s guideline on intermediate care including reablement, terms used in this guideline section]
Transition plan
The transition plan should be documented, and include:
  • information about how the person can refer themselves back into the intermediate care service if their needs or circumstances change
  • contact details for the service they are being referred to or any services that are restarting (if appropriate)
  • information about potential costs of any ongoing social care services
  • a contingency plan should anything go wrong
  • information about other sources of support available, including support for carers.
[NICE’s guideline on intermediate care including reablement, recommendations 1.7.1, 1.7.2 and 1.7.3 and expert opinion]

Equality and diversity considerations

Individual cultural and religious needs should be taken into account when identifying options for ongoing support services following intermediate care.
Discussions about a transition plan for when support from the intermediate care service ends may need to be adapted to meet the needs of people living with cognitive impairment, including dementia, and their family and carers. Healthcare professionals should ensure that the person living with cognitive impairment is supported by a relative or carer or an advocate as appropriate.

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Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

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.
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).
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.
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 usually delivered by a multidisciplinary team but most commonly by healthcare professionals or care staff (in care homes).
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).
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.
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.
This involves balancing the positive benefits gained from taking risks against the negative effects of attempting to avoid risk altogether.
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.
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.
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 what NICE says on transition between inpatient hospital settings and community or care home settings for adults with social care needs.
Give people information about other sources of support available at the end of intermediate care, including support for carers.

Glossary

Paths in this pathway

Pathway created: September 2017 Last updated: August 2018

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