Best practice for
community living
through
Intermediate care
and reablement:
A complex case
discussion
Fiona Howlett
May 2012
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York St John University | www.yorksj.ac.uk
1
Plan for the session
• Brief summary of intermediate care and
reablement
• Discussion around complex case scenario
• Implications for the work/resources
required
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What is Intermediate Care?
• Intermediate care is a range of integrated
services designed to:
• promote faster recovery from illness
• prevent unnecessary acute hospital admission
and premature admission to long-term
residential care
• support timely discharge from hospital and
maximise independent living.
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Essential elements within
Intermediate Care
Services are
locally based
Multi
professional/multi
agency teams
Care provided
close to home
Focus is on
restoring or
maintaining
function
Services are
short term
Rehabilitative
approach
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Key drivers for the development
of Intermediate Care
Pressure on
acute hospital
beds
NHS financial
pressures
Local authority
financial
pressures
More older
people with long
term chronic
conditions
Patient choice
Reimbursement
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Intermediate care services are
based on:
• Comprehensive, multi professional, multi agency
assessment - in line with the single assessment
process (DH 2001)
• Provision of a structured individual treatment
plan which includes active therapy, treatment or
opportunity for recovery.
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How is Reablement different to
Intermediate Care Services?
• Services for people with poor physical or mental
health to help them accommodate their illness
by learning or re-learning the skills necessary for
daily living. (Care Services Efficiency Delivery
programme 2007)
• Helping people to maximise their independence,
choice and quality of life
• Helping people to remain in their own homes
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Reablement
• Providing time limited interventions with services
tailored to individual’s needs (Care Service
Efficiency Delivery programme 2007
• Reablement ‘seeks to maximise long term
independence, choice and quality of life, whilst
minimising the ongoing support required’
Pilkington 2008 p.355
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How does this differ from
Intermediate care?
Hospital
(secondary care)
Intermediate care
(may be primary
or secondary care
depending on
location)
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Reablement
(Predominantly
Social care)
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Guiding principles
• Person-centredness: Service users should have
more control and choice over their support
• The role of adult social care is to help people to
maintain or regain their independence,
regardless of age, impairment, ethnicity or
personal circumstances
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Mrs Brown
• Mrs Brown is a 68 year old woman
• Until recently she had shared her privately
rented terraced house with her partner of 20
years
• Partner had recently died in traumatic
circumstances and she was coming to terms
with her loss
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Presenting Medical Issues
• Chronic lymphodema affecting both legs.
• Both legs are ulcerated and require daily
dressing
• Osteoarthritis affecting both hips and knees
• Obesity
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Social Support systems
• No family
• Two good friends who live locally
• Mrs Brown does not know neighbours as
neighbouring properties also rented and
neighbours change frequently
• No help at home other than District Nurses who
visit daily to dress Mrs Brown’s ulcerated legs
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Presenting problems and
reasons for referral
• Referral to the Intermediate care team by the
District Nurses
• Presenting difficulties were:
• She was not able to mobilise safely around her
home
• She could not access her toilet
• She could not access her bathroom
• She could not access her kitchen
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Presenting problems continued..
• Mrs Brown’s house was very cluttered and
inaccessible
• There were dogs, a cockatiel, two snakes in a
vivarium and mice running around the property
• Basic needs were met at ASDA (Wal-Mart) via
scooter
• Risks +++
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Street of terraced houses
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A fairly typical terraced house
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Narrow hallway
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Narrow stairs
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Dining room
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Galley Kitchen
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Sitting Room
.
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York St John University | www.yorksj.ac.uk
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.
York St John University | www.yorksj.ac.uk
What did the team do?
• Responded to the referral within 2 hours and
completed a risk assessment
• Admitted Mrs brown to an Intermediate care
team bed in a local nursing home.
• Contacted environmental health department to
remove the dead mice and put down bait for the
living mice
• RSPCA took away the snakes and arranged
foster care for the dogs and a friend looked after
the bird in the cage
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Mrs. Brown’s Goals
• To be able to get washed and dressed with
minimal assistance
• To be able to access the toilet and get on /off the
toilet safely
• To be able to prepare meals safely
• To be able to mobilise around her home safely
• To live in a property which meets her needs and
in which she feels safe
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Ethical Issues/
Diversity of living conditions?
• Some individuals may stray from societal norms
of cleanliness and hygiene
• What are the ethical and practical issues for
professionals?
• How can you respond to the challenges?
• What are the potential solutions?
• Would you offer Mrs Brown any interventions,
and if so where?
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Ethical issues in practice
• There is an ethical dimension to most of what we do in
the workplace (Hendrick 2004).
• Professionals need to be able to recognize these and
consider the implications for the individual, their families
and carers.
• Campbell, Chin and Voo (2007) identify that medical
ethics is not the concern of one professional group or
discipline but is a matter which should be approached
from a multi-disciplinary perspective having relevance to
all professionals working in health and social care.
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Resolving ethical dilemmas
• Informed by professional codes of practice
• It has been argued that Codes of conduct should be
used as a framework for guidance but cannot be
expected to resolve complex ethical dilemmas (Terry
2007).
• Supervision
• Multi disciplinary team discussion
• Grids/frameworks/models may help but need to
remember that applying ethical decision making models
does not produce bias free decisions as personal values
will still impact on upon this process (Mattison 2000)
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Need to consider..
• Balancing risk with harm
• Positive risk taking
• Respecting autonomy and choice
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What Model of practice might
you use and why?
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Person-Environment-Occupational
Performance Model
Person
Perform
ance
Environ
ment
Occupation
Baum, Bass, Christiansen
(2005)
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Person Level issues
Occupation
Health
Strengths
Needs
Goals
Wishes
Meanings
Risks
Activity task role
What/How/when
Supports
Preserved activities
Bingo/social outings
Risks
Benefits
Occupational
Performance
Environment
Where/Who with?
Supports
Demands/
Home environment
Risks
Benefits
Community engagement
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Canadian Model of Occupational
performance and engagement
www.yorksj.ac.uk
Townsend and Polatajko
2007
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Canadian Model of Occupational
performance and engagement
•
•
•
•
Self-care
Washing/dressing
Showering
Toileting
•
•
•
•
Leisure
Walking dogs
Going to bingo
Social events – risk of
social isolation
• Productivity
• Preparing meals
• Maintaining home
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Person centred assessment
• Use active observation
– Standing back – allowing person to be themselves
and be “in the flow” of activities
– Observe the person’s own strategies, routines and
pathways and build on them
– Use activity analysis and synthesis
• Mixed methodology - Informal, formal, standardised and
dynamic
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Person centred assessment
• Working with the person in their lived environments:
• Physical environment
– creating accessible and enabling environments, role
of assistive technology and adaptations
• Social and cultural environment
– Reducing stigma
– Reducing occupational deprivation
– Promoting positive communication
– Supporting and enabling carers
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Which assessments would you
choose and why?
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Assessments
•
•
•
•
•
Observation of Activities of daily living
FIM/FAM (base line) Granger et al (1993)
COPM (Law et al 2005)
AMPS (Fisher 2003)
Homefast (Mackenzie et al 2000)
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What interventions might you
choose and why?
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What interventions and why?
• Maintain or improve upper/lower limb strength, ROM
and tolerance
• Maximise ADL
• Ensure safety and accessibility in the home Rehousing
• Assess need and make recommendations for
equipment/adaptations
• Explore interests/reduce social isolation
• Assist with psychological adjustment to problems
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Who was involved?
•
•
•
•
District Nurse
Physiotherapist
General Practitioner
Consultant
orthopaedic surgeon
• Therapy Assistants
• Dieticians
• Environmental Health
Officers
• Local Housing
Department
• Friends
• Foster carers for the
pets
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Outcome
• Mrs Brown was re-housed within 8 weeks to a
local Housing Authority owned bungalow which
already had a level access shower
• A hoist was provided for the days when Mrs
Brown’s mobility was severely impaired by pain
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Outcome
Mrs Brown required bariatric equipment to meet
her needs:
• Wheelchair
• Shower chair
• Rise recliner chair
• Profiling bed
• Glideabout commode
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Outcome
• Mrs Brown received a package of care which involved
carers visiting 4 times each day to assist with personal
care, meal preparation and walking her dog - provided
free initially for 6 weeks
• Transferred to reablement team then to private care
team then she would need to pay for her care through
Local Authority
• Her dogs and budgie were returned to her
• The snakes were not!
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Implications for work/resources
•
•
•
•
•
•
•
Services are free at the point of delivery
Response times 2 hours from receipt of referral
Therapy services 7 days per week
Extended hours of working
Services are time limited to 6 weeks
Services are provided close to home or in the home
Collaboration with the older person and their carers
essential
• Collaboration with other team members essential
• Role blurring common
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References
• Baxter S & Brumfitt S (2008) Professional differences in
interprofessional working Journal of Interprofessional Care 22 (3)
239-251
• Campbell A, Chin J and Voo T (2007) How can we know that ethics
education produces ethical doctors? Medical Teacher 29 p 431-436
• Baum C, Bass J, Christiansen C (2005) Person- environmentoccuaptional performance: a model for planning interventions to
individuals and organizations. In Christiansen C, Baum C, Bass J
(Eds) Thorofare. New Jersey.Slack inc.
• DH (2000) NHS Plan. London: The Stationary Office.
• DH (2001) National Service Framework for Older People. London:
The Stationary Office.
www.yorksj.ac.uk
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References
• DH (2005) National Service Framework for people with long term
conditions. London: Stationary office
• DH (2009)Intermediate Care: Half way home London: The
Stationary Office
• Fisher AG, (2003a) Assessment of motor and process skills 5th
edition. Fort Collins,CO. Three Star Press
• Glendinning C,(2003) breaking down the barriers: integrating health
and social care for older people in England. Health Policy 65 (2)
139-151
• Granger CV, Hamilton BB, Linacre JM, Heinemann AW, Wright BD
(1993). Performance profiles of the functional independence
measure. American Journal of Physical Medicine and Rehabilitation.
72(2), 84-89
www.yorksj.ac.uk
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References
• Hoffman SJ, Rosenfield D, Gilbert JHV, Oandasan IF (2007),
Student leadership in interprofessional education; benefits,
challenges and implications for educators, researchers and
policymakers. Hughes L, Marsh L and Lamb B (2006) Creating an
Interprofessional Workforce
• Hammick M, Freeth D,Copperman J, & Goodsman D (2009) ‘Being
Interprofessional’. Cambridge. Polity Press
• Hendrick J (2004) Law and Ethics. Foundations in Nursing and
Healthcare. Cheltenham. Nelson Thornes.
• Law M, Baptiste S, Carswell (2005) Canadian occupational
performance measure. Toronto. CAOT publications.
www.yorksj.ac.uk
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References
• Mackenzie L,Byles J, Higginbotham N, (2000) Designing the home
falls and accident screening tool. (HOMEFAST): Selecting the items.
British Journal of Occupational Therapy 63(6), 260-269
• McDermott K, Linahan K and Squires B J (2009) Older People
Living in Squalor: Ethical and Practical Dilemmas Australian Social
Work Vol 62, No 2 pp245-257
• Northern health (2004) Patients first: Optimizing Inter-professional
Team Work. Report on current practices. Prince George, BC,
Northern Health project
• Pilkington, G (2008) Home care reablement: Why and how providers
and commissioners can implement a service. Journal of Integrated
Care. 16 (2) 38-40
www.yorksj.ac.uk
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References
• Terry L (2007) Ethics and contemporary challenges in health and
social care. In Leathard A and McLaren S (eds) Ethics and
contemporary challenges in health and social care, pp 25 Bodmin:
The Policy Press
• Townsend,EA Polatajko,HJ (2007) Enabling occupation 11:
Advancing an occupational therapy vision for health well-being and
justice. CAOT publications ACE. Ottawa ON.
• Seedhouse D (2005) The Moral Context of Practice and
Professional Relationships, In Occupation& Practice in Context
Whiteford G and Wright-St Clair (Eds) Australia
Elsevier
www.yorksj.ac.uk
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Programming
with elders:
A summary
Fiona Howlett
www.yorksj.ac.uk
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Summary:
Programming with elders
•
•
•
•
•
•
•
•
•
Or, interventions with older people
Services driven by Department of Health policy guidance
Services driven by ageing population
Services are designed to meet the needs of local populations
There is not always a blueprint for how services should be
delivered
Freedom to be able to work in a person centred way with an
older person
Interventions are focussed on the older person’s goals
Services remain free at the point of delivery
Services are time limited
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A thought to leave you with..
• Older people must not be left to find their way
around the hospital system or left in a hospital
bed when supported care or rehabilitation is
what they need
• They must receive the right care in the right
place at the right time. NHS Plan DH (2000)
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