With a strong commitment to reducing admissions to residential care for people with mental health needs, Herefordshire County Council and Herefordshire Mental Health Services took a new approach to intermediate care, co-ordinating 3 services to provide 24 hour support:

• A mental health intermediate care team, working with SureCare Services specialist domiciliary care provider
• Just Checking
• Roving Night Team

A net "importer" of older people, and with a large geographical area, Herefordshire had historically encountered considerable problems in organising domiciliary care in its rural areas, and there was virtually no domiciliary care for people with dementia.

Herefordshire created a partnership with SureCare Services to train home carers in the reablement of people with dementia, placing therapy based approaches at the heart of the service.

Referrals to the intermediate care service come at a crisis point or on discharge from hospital. Deciding how best to support the person requires a good understanding of the person’s history and an objective assessment of how they are managing in their own home, using Just Checking. The 24 hour activity monitoring system provides a clearer picture of how a person is coping when they spend time alone, allowing support services to be targeted appropriately and with relevance. An intensive care plan is drawn up. SureCare’s visits are scheduled for a minimum of an hour, so that staff can engage fully with the service user and stimulate reablement. A range of telecare devices are used to manage specific risks.

The Just Checking activity charts are shared with family members, who can see for themselves the level of risk or concern, and work with the professionals on how best to manage the care a person needs.

Interestingly, it is often the case that a person with dementia holds on to clear daily routines, and functions better than expected in their own home, where familiar surroundings provide cues and reminders. Even when a high level of confusion has been displayed in hospital, this often disappears when the service user is home and re-orientated. The effect of services, and a gradual stepping down as the service user does more, can be monitored via the activity charts.

The Roving Night Team provides support for those who need it. Two mobile reablement carers make calls only if required, logging on to the Just Checking website via smart mobile phones as they leave one property, to check if the next person needs a call. And the team has the capacity to respond to night-time wandering or emergencies.

Evaluation - 1 Year Outcomes

Residential admission rates were reduced by 43% in the pilot area of the county. At 1 year, of the first 37 users of the service:

• 57% were still living at home
• 2/3 of those needed only low level on-going support

On-going care support	Category	Percentage
Independent/family support, Carer service or Supporting People	Low	33%
Up to 7 hrs/wk	Low	19%
7 – 14 hrs/wk	Low	14%
14-21 hrs/wk	Medium	19%
Over 21 hours /wk	Medium/High	10%
24 hour support at home	High	5%

For a copy of the full 1 year outcomes report please contact Jodie Thomas, Care Facilitator, jodie.thomas@herefordpct.nhs.uk

Download the pdf leaftlet here

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