Pioneering Intermediate Care
43% reduction in admissions to residential care
Committed to reducing admissions to residential care for people with dementia, 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
Herefordshire created a partnership with SureCare Services to train home carers in the reablement of people with dementia.
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. 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 charts are shared with family members, who can see for themselves the level of risk, and work with the professionals on how best to manage the care a person needs.
It is often the case that a person with dementia functions better than expected in the familiarity of their own home. Even when a high level of confusion has been displayed in hospital, this usually disappears when the service user is back 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. 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
