Supporting people at home with intermediate care

In April 2020 Somerset NHS launched a fully integrated intermediate care service, following the success of their Home First initiative.

Studies suggest the best place to recover is at home. People who are admitted to hospital often lose their independence very quickly, which makes it harder for them to get home and back to doing the things they enjoy. In fact, just 10 days of bed rest for healthy older people can equate to 10 years of muscle ageing and loss of function.

People in hospital beds can often be cared for elsewhere. Also, assessments of a person’s ability are more accurate when carried out at their home, where it is clearer to see what they can and can’t do.

Rehabilitation and reablement not only leads to the best outcomes for the person, but also offers significant longer term cost savings for the NHS.

Somerset’s Intermediate Care was built on existing hospital discharge and admission avoidance services such as Home First and Rapid Response.

These services had an immediate impact and, by April 2020, we realised that combining and expanding admission avoidance and hospital discharge services together would create a stronger, more agile way of helping people to recover and remain at home.

What we do

Somerset Intermediate Care Services are run jointly by NHS Trusts in Somerset and Somerset County Council and bring together other providers such as care homes, homecare agencies and voluntary services. Together, we support acute hospital discharges and prevent admissions.

Intermediate Care provides support to help people:

  • remain at home when they start to find things more difficult
  • recover after a fall, an acute illness, or an operation
  • avoid going into hospital unnecessarily
  • return home more quickly after a hospital stay

How we do it

Centred on a ‘home is best’ ethos, we work with all the services involved in patient discharge and prevention of hospital admissions. The service offers people varying levels of support, with the ultimate aim of getting them back home as soon as they are well enough, and back to their normal standard of independence as soon as possible.

Before leaving hospital, staff discuss and agree the patient’s needs and discharge arrangements with the patient and, if appropriate, their family.

Each person returning home will have a key worker, as well as experienced reablement staff, working with them to set and achieve goals to help them regain their independence.

For those people whose needs are too complex to return directly home, Somerset Intermediate Care Services offer a range of community-based rehabilitation and reablement units to support their initial recovery, before eventually returning home again.

Working together

Our Intermediate Care service is the result of five years’ work to foster greater collaboration between NHS, local authority and voluntary sector services.

Somerset Intermediate Care incorporates the following services:

  • Somerset County Council
  • NHS Somerset
  • Yeovil District Hospital NHSFT
  • Somerset FT
  • Voluntary sector
  • Care homes
  • Homecare agencies

All partners are focussed on joint working and shared practice. Supported discharge decisions are made by multi-disciplinary teams away from wards and assessments are carried out in a person’s home, or an intermediate care rehabilitation or reablement unit

The voluntary and community sector is an important part of the intermediate care team. These teams support people with their recovery at home after a period in hospital or avoid unnecessary hospital admission altogether.

The whole system has been transformed, from the creation of a central Somerset Hub for Coordinating Care to community beds being coordinated and monitored from one place. The Head of Intermediate Care for Somerset has access to all data from all partner services, which can be shared and analysed to help the service improve.

There is also strong collaboration at neighbourhood level across district nursing, adult social care locality teams, mental health social workers and health professionals, occupational therapists, primary care networks, community pharmacies and voluntary care services.

Measuring Success

Our integrated approach has resulted in far fewer unnecessary hospital admissions while substantially reducing numbers going into long-term placements directly from hospital.

Every month, we have succeeded in getting 91%- 95% of over 65s home from hospital, breaking down the traditional silos that can exist between health and care providers, enabling better use of resources and improving outcomes for people.

Multi-disciplinary teams are now the norm across intermediate care thanks to the strength of the partnership. Decisions around pathways and bedded placements are now made with a far clearer picture of the person’s wants and needs and involve input from all relevant disciplines.

The partnership has nurtured a shared understanding across health and local government of the levels of demand in the system, and the importance of getting people back to their usual place of residence.

Sharing success

Senior managers from health and local government regularly present to key stakeholders such as NHS, council directors and other system leaders across the country who are looking to learn from Somerset’s experience.

The service has informed a report called The Age of Intermediate Care, which details how better outcomes can be achieved through deeper integration and the importance of intermediate care in meeting the needs of an ageing population. 

We have also held briefings with health and social care teams around the country about the intermediate care model developed in Somerset and ran a Local Government Association webinar on the service, attended by over 100 people from social health and care organisations.