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Aging & Mental Health
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Delayed discharge - a solvable problem? The place of
intermediate care in mental health care of older people
J. M. Paton a; M. A. Fahy a; G. A. Livingston a
a
University College London, Department of Psychiatry, London, UK
Online Publication Date: 01 January 2004
To cite this Article: Paton, J. M., Fahy, M. A. and Livingston, G. A. (2004) 'Delayed
discharge - a solvable problem? The place of intermediate care in mental health
care of older people', Aging & Mental Health, 8:1, 34 - 39
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Aging & Mental Health, January 2004; 8(1): 34–39
ORIGINAL ARTICLE
Delayed discharge—a solvable problem? The place of intermediate
care in mental health care of older people
J. M. PATON, M. A. FAHY & G. A. LIVINGSTON
University College London, Department of Psychiatry, Highgate Hill, London, UK
Abstract
The National Service Framework for Older People envisages the development of intermediate care for older people. This
study examined the possible role of intermediate care beds within mental health trusts. We interviewed senior clinicians in an
inner city old age psychiatry service about the 91 current in-patients on the old age psychiatric wards. Sixty-five were
classified as acute patients and the remaining 26 were continuing care patients. Structured instruments were used to collect
information regarding neuropsychiatric symptoms, activities of daily living and current met and unmet needs. Where
discharge was delayed an assessment was made regarding the appropriateness for an intermediate care setting according to
the criteria set by the Department of Health guidelines. A total of 30 (46%) patients’ discharges were delayed. Of these, 19
(29%) patients met the DOH criteria for intermediate care; 10 (53%) had dementia, five (26%) affective disorder, and four
(21%) with schizophrenia. The 11 other delayed discharges were because of lack of availability of finance for placements.
The study found that the prompt discharge of older patients from acute psychiatric care was a significant problem and many
of those patients may benefit from the therapeutic and rehabilitative process afforded by intermediate care.
Introduction
The National Service Framework for Older People
(NSF) sets out a vision of intermediate care as a ‘vital
component of the programme to improve the health
and well-being of older people and raise the quality
of services they receive’ (Department of Health,
2001). Intermediate care (IC) is defined as ‘a range
of integrated services to promote faster recovery
from illness, prevent unnecessary acute hospital
admission, support timely discharge and maximise
independent living.’ The NSF recommends the
establishment of IC beds within all older people’s
services and generally sets a six-week upper limit for
intermediate care. Government policy sees IC not as
an optional extra for older peoples’ services but as
central to the modernisation agenda. The government has announced its intention to create 5,000 IC
beds by 2004 in a variety of settings such as hospitals,
patient’s homes and nursing homes (Pollock, 2000).
About 6% of patients in acute general medical
wards at any one time are awaiting discharge
(Robinson, 2002). There has been less research on
this problem within psychiatry, although one study in
older psychiatric patients found that about 40% of
bed days were used for patients whose discharge had
been delayed (Draper & Luscombe, 1998). The
mental health of older adult in-patients often
improves while in an acute psychiatric ward but
may, however, remain at a level such that patients
continue to require significant help while no longer
needing to be in an acute psychiatric ward. It might
be expected that IC would be appropriate in these
circumstances. Yet within mental health care for
older people there is currently no alternative to acute
admission beds other than community treatment,
respite care or long-term 24-hour care. While there
are IC schemes for older patients with physical illnesses, IC for older psychiatric patients is uncharted
territory, as the schemes have not been piloted in
mental health.
The research base for IC is limited and confined to
physical health. What research there is shows overall
patient and carer satisfaction and a moderate
reduction in admissions and delayed discharge.
There may be difficulties with the IC model; for
example, the somewhat arbitrary time limit of six
weeks and the new suggested role of primary care in
established physical services is proving problematic.
After six weeks of intensive rehabilitation and service
provision the general practitioner (GP) is then left
to continue care often with increased expectation of
Correspondence to: Joni M. Paton, University College London, Department of Psychiatry, Holborn Union Building,
Highgate Hill, London, N19 5LW, UK. Tel: þ44 (0) 207 288 5931. Fax: þ44 (0) 207 288 3411. E-mail: j.paton@ucl.ac.uk
Received for publication 29th November 2002. Accepted 4th May 2003.
ISSN 1360-7863 print/ISSN 1364-6915 online/04/01034–06 ß Taylor & Francis Ltd
DOI: 10.1080/13607860310001613310
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Delayed discharge—a solvable problem?
35
Aim
The aim of IC is to provide integrated services to promote faster recovery from
illness, prevent unnecessary acute hospital admissions, support timely discharge and
maximise independent living.
Standard
The standard is that older people will have access to a new range of IC services at
home or in designated care settings, to promote their independence by providing
enhanced services from the NHS and councils to prevent unnecessary hospital
admission and effective rehabilitation services to enable early discharge from hospital
and to prevent premature or unnecessary admission to long term residential care.
Intermediate care services should:
• Be targeted
• Be provided on the basis of comprehensive assessment
• Be designed to maximise independence
• Involve short-term interventions
• Involve cross-professional working
• Be integrated within a whole system of care
Intermediate
services
should:
• Havecare
an upper
limit
of time spent there of six weeks
FIG. 1.
three).
Summary of NSF intermediate care standard. The aim and the standard of IC is outlined in the NSF (standard
what can be provided. Intermediate care comes
under the remit of general medical services (GMS)
and GPs are not paid extra for GMS.
MacMahon (2001) argues that although minimising the duration of hospital stays by older people is
important, he warns against the risk of IC ‘being
used as a euphemism for indeterminate neglect’.
Intermediate care could be a way of making older
people’s care a ghetto service, by denying them the
appropriate care in mainstream services or leaving
older people in a cheaper bed without solving the
problems that prevent discharge, for example finding
an appropriate long-term home. If the only problem
preventing appropriate discharge is funding by the
cash-strapped social care system, it is important that
patients are not left in an intermediate care bed
instead of a permanent home. It is also not an
alternative to the well-established community mental
health teams that provide home treatment.
The current study considers the role of intermediate care for older psychiatric patients by assessing,
firstly whether in-patients in an inner London mental
health and social care trust were being cared for in
the appropriate setting. Secondly, we considered if
patients who were not in the appropriate setting
would meet the criteria for an intermediate care bed
(see Figure 1).
Methods
The setting
The study took place in a NHS mental health and
social care trust, which serves a deprived inner-city
area with a population of about 500,000 people.
The interview
A research psychologist (JP) interviewed doctors and
senior nurses regarding each patient on all of the
older adult psychiatric wards in the Trust and
administered a battery of standardised instruments
and attended eligibility panel meetings. The research
psychologist (JP) recorded the number of days since
admission, and whether the patient was recorded as a
‘delayed discharge’. The definition of delayed
discharge within the Trust was the period that
started on the day when the consultant in the context
of a multi-disciplinary team review had decided that
the patient was ready for discharge.
Instruments
The Camberwell Assessment of Need for the Elderly
(CANE). This was administered by the research
psychologist (JP) who gained information from
professional staff. She discussed her ratings with
the other two authors, who are both experienced
clinicians and researchers, to ensure that the data
was scored reliably. The CANE measures the
number of met and unmet needs in older people
according to patient, carer and staff report (Reynolds
et al., 2000). It has good content, construct and
consensual validity. It also demonstrates appropriate
criterion validity. Reliability is generally very high:
kappa > 0.85 for all staff ratings of inter-rater
reliability. Correlations of inter-rater and test-retest
reliability of total numbers of needs identified by staff
were 0.99 and 0.93, respectively. Unmet needs score
as two, and no needs as zero, met needs as one.
A met need is when an individual has difficulty but
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36
J. M. Paton et al.
the difficulty is being provided for. An unmet need
is again regarded as an area when there is a difficulty
but the individual is not receiving the appropriate
level of assessment or treatment. The needs assessment covered the following items: accommodation, looking after the home, food, self-care, caring
for someone else, daytime activities, memory, eyesight/hearing, mobility, continence, physical health,
drugs, psychotic symptoms, psychological distress,
information, deliberate self-harm, accidental selfharm, abuse/neglect, behaviour, alcohol, company,
intimate relationships, and money and benefits.
The Neuropsychiatric Inventory (NPI). Cummings
et al. (1994) scores both frequency and severity of a
range of psychiatric symptoms other than memory
for patients (e.g. hallucinations, aggression, depression) with dementia and other neurological illnesses.
There are 14 symptom areas covered. Possible scores
range from 0–144 and is reached by multiplying
frequency by severity of individual items and adding
them together. Higher scores indicate increased
severity. It has good content and concurrent validity
as well as inter-rater and test-retest reliability.
Cummings and his colleagues (1994) tested a 10-item
version of this instrument in a control population
(older people without psychopathology) and in
people with dementia attending out-patients. The
mean scores were respectively 0.43 and 8.25. The
mean NPI score in a previous study of the same
continuing care wards as in this study was 10.4 (Fahy
& Livingston, 2001)
The Abbreviated Bristol Activities of Daily Living
Scale. (The Bristol ADL: Bucks et al., 1996) is
divided into two domains: (1) instrumental activities
(food, eating, drink, communication, telephone,
housework, shopping) and (2) self care (drinking,
dressing, hygiene, teeth, bath/shower, toilet/commode). A higher score indicates increasing dependency. Possible scores range from 0–39. If an item
is not applicable it scores 0. For example when
a patient never shopped for himself or herself
because they were in a wheelchair or because their
partner had always done it. It has satisfactory face
validity, construct validity, and concurrent validity as
well as test-retest reliability.
Eligibility panel
The eligibility panels meet weekly to consider
appropriate placement of older people. The panel
decisions are about 24-hour care settings, or care
packages over a threshold financial amount, and are
for all patients, whether or not the patient is
financially independent. It ensures that patients
needs meet eligibility criteria and so they are placed
appropriately. For example, they looked closely at
behavioural problems and risks and discussed how
this could be managed in differing placements.
There was no discussion of funding as the panel
decides only eligibility. JP attended the eligibility
panels to clarify the process and how decisions
are made.
Consultant interview
JP interviewed the consultants with regard to each
patient responsible. The interview covered the
following questions:
1. Diagnosis—consultant diagnosis.
2. What ideally should happen to the patient in terms
of discharge.
3. Are they in the optimal setting?
4. If not, why not and what would be an appropriate
placement for the patient.
Analysis
The reasons for delayed discharge were recoded into
four categories:
1. Lack of specialist staff resources for placement or
returning home (encompassing not being allocated to a social worker, placement panel reports
not being completed, not being presented to the
placement panel, a place not being found after
approval by the panel, and awaiting package of
care and/or intensive clean).
2. Lack of money to finance placement for example,
local service services said money was not available
at present.
3. Lack of an alternative to acute ward when the
patient no longer needs acute care.
4. Miscellaneous (e.g. relative or family refuses to
pay for placement, or placement offered deemed
unsuitable for patient or family).
Results
There were seven Mental Health Care of Older
People (MHCOP) wards with 91 occupied beds.
There were 56 patients in the acute wards and 35 in
continuing care (CC). Of the patients in CC wards,
nine had been placed there temporarily. They did
not meet the criteria for CC and there was no
intention that they remain there in the long-term.
The rest of the results will focus on these 65 (56 in
acute, and nine temporarily in CC) patients who
were not intended to stay in hospital permanently.
The mean age of patients was 76 years old, (range
63–96 years). Two patients were under 65 (3%) of
whom one had depression and one had schizophrenia, and both were physically frail. Twenty-three
(35%) were male, 46 (71%) were White British,
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Delayed discharge—a solvable problem?
three (5%) Greek-Cypriot, five (8%) were White
other, four (6%) were Black African/Caribbean and
one was Asian. The most common diagnosis was
dementia 26 (40%), followed by affective disorders
22 (34%), and 22 (34%) patients had enduring
psychoses. There were two (3%) with personality
disorder, one with a learning disability and two (3%)
who had not yet received a diagnosis. The mean
length of admission was 109 days (four days to 3.2
years). Patients scored highly on the both the NPI
(mean ¼ 27; range ¼ 1–112) and Bristol ADL
(mean ¼ 11; range ¼ 0–36).
There were 30 (46%) patients whose discharges
were delayed. These delayed discharges were for
the following reasons: 15 (30%) insufficient specialist
staff resources for placement or returning home; six
(20%) lack of money to finance placement; six (20%)
no alternative to acute ward when the patient no
longer needs acute care. The final three (10%)
delayed discharges were in the miscellaneous category (two relatives refused to pay for placement; one
relative and patient turned the placement down).
Following DOH guidelines, 19 (29%) candidates
were suitable for IC (12 in category 1, six in category
3 and one in category 4). The group identified for
IC had a median length of admission of 86 days
(12 days to 3.2 years), median total NPI score of
25 (1–103), and median Bristol ADL score of 11
(0–29). The most common diagnosis was dementia
(10; 53%), followed by affective disorders (5; 26%)
and schizophrenia (4; 21%).
The CANE identified the following unmet needs:
accommodation ¼ 32 (49%), help with self-care ¼ 30
(46%), being vulnerable to abuse from others and
needing additional help with looking after the home
(both ¼ 26; 40%). Other frequent unmet needs were:
management of risk of accidental self-harm ¼ 21
(32%), help with providing themselves with
food ¼ 21 (32%). Less common unmet needs were
help with memory ¼ 15 (23%), behaviour ¼ 11 (17%),
continence ¼ 10 (15%), company ¼ 8 (12%),
alcohol ¼ 7 (11%), daytime activities, intimate relationships and managing medication (all 9; 14%).
There were relatively few unmet needs in the
categories of psychological distress and deliberate
self-harm both ¼ 6 (9%), money ¼ 3 (5%), mobility,
benefits, caring for someone else all ¼ 2 (3%), and
physical ¼ 1 and psychotic symptoms ¼ 1.
The commonest unmet needs identified by the
CANE for the 19 patients who met DOH IC criteria
were: accommodation (16; 84%), looking after the
home, needing help with self-care (both 12; 63%)
and inadvertent self-harm (9; 47%). Many patients
had unmet needs for help with getting enough food
(8; 42%) or with managing medication, being
vulnerable to abuse from others and needing help
with memory (all 5; 26%). Less common unmet
needs were the need for help with continence
(4; 21%); difficult behaviour (3; 16%) and management of alcohol problems (2; 11%). Individuals had
37
TABLE 1. Mean number of met and unmet needs in
Intermediate care and non-intermediate care groups
Intermediate care
Non intermediate care
Mean number
of met
needs (SD)
Mean number
of unmet
needs (SD)
9 (3.1)
10 (3.4)
4 (2.6)
2 (3.1)
unmet mobility needs, unmet needs for intimate
relationships, daytime activity, psychotic symptoms,
psychological distress and company (all 1). Table 1
shows the mean number of met and unmet needs in
the intermediate care and non-intermediate care
groups. Wilcoxon signed ranks showed a significant
difference ( p 0.05) with a higher mean number of
unmet needs in the group that met DOH criteria for
IC, compared to the non-intermediate care group.
Discussion
This study found that about 40% of patients in acute
MHCOP wards were no longer in the appropriate
setting. In this study, as in others, some patients who
were admitted to an acute ward and return to their
pre-morbid functioning were discharged without
delay to their home (Moss et al., 1995; Cohen &
Casimir, 1989). The patients whose discharge had
been delayed remained in an acute (or occasionally
continuing care) ward until, for example, their
homes were adapted or cleaned, there was an
increase in care package or long-term care was
arranged. Not only were this group of patients not in
the optimal environment but also, this environment
may be positively harmful in terms of risk from other
peoples’ behaviour or iatrogenic illness (Steiner,
2001), for example, patients could be harmed by
an acutely disturbed patient.
Most of them had been in these beds for about
three months. A few had longer delays and some of
these were due to family disputes, which might also
affect IC settings even when other difficulties had
been sorted out. The focus on sorting out discharge
would however mean these problems would be
prioritised. Nevertheless it would not always be
realistic in mental (or physical) health to discharge
all patients from IC at six weeks however well laid the
plans were. There were some patients whose
discharges were delayed because they no longer
needed an acute admission ward but needed active
rehabilitation before they went home. There were
others whose homes were not suitable to go to
(usually because of the patient’s extreme neglect
before admission). Many patients could have benefited from active rehabilitation and increasing their
daily living skills. In addition, there were patients
who did not need an acute ward but needed a new
place to live with 24-hour care. These placements
could not be found instantaneously due to a number
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38
J. M. Paton et al.
of reasons, including assessment, patient and carer
preference and appropriate places were not necessarily available. This process is complex and time
consuming.
Those patients who had recovered enough to not
need an acute ward but were not ready to be
discharged home required a setting to target faster
recovery from illness, support timely discharge and
maximise independent living through integrated
services. Some sort of step-down care to avoid the
disadvantages of remaining in an acute ward was
needed at this juncture. Most of these patients
required 24-hour care and thus a home treatment
scheme could not meet their needs, unless it provided round the clock one-to-one care. This would
be an extremely expensive option and would not
meet the needs of those who needed rehabilitation
or whose homes were uninhabitable.
Intermediate care
Individuals in our study had a complex spectrum of
unmet needs, for example, alcohol abuse, neuropsychiatric symptoms and psychological distress, and
therefore input from all members of the multidisciplinary team would be essential. An intermediate care service where there was integrated health
and social services consisting of social work, occupational therapist, psychology, nursing and medical
input would be a solution. As most of these patients
had high numbers of neuropsychiatric symptoms
(much greater than psychiatric out-patients or those
in continuing care) it would be inappropriate to place
them in an IC setting which had been set up for the
needs of people whose main problem was a physical
illness. A dedicated psychiatric facility was therefore
necessary. If the staffs’ major roles were rehabilitation, assessment for appropriate placement and
finding the right setting for the patient to live, then
the patients’ function would be maximised and their
discharge expedited.
Some of the patients whose discharge was delayed
had been found suitable placements but had not
moved from the acute wards, as funding was not
available. They were not suitable for IC because their
only need was funding which would not be provided
in an IC environment and if they moved to IC, it
would be in danger of becoming a parking service
rather than a rehabilitative or assessment service.
We have discussed our study and its findings with
all the consultant psychiatrists involved in the
patients care, psychologists, occupational therapists,
social workers, nurses, commissioning groups and
health service managers. The professionals identified
a significant problem with delayed discharges and
this reduced access to acute beds. Whilst IC was
judged to be an appropriate solution there were
concerns that IC would be used instead of placing
people rapidly in an appropriate community
resource. The separation of mental health and
primary care trusts has increased the complexity of
partnerships needed to commission such services
(Herbert, 2002). The evidence in our study indicated
that there were already substantial delays in discharge from the acute wards. A dedicated psychiatric
IC service would aim to tackle this problem. We have
however not consulted with patients and carers and
think that is a necessity before final decisions are
made. In addition, we have not studied the patients
who might benefit from IC by prevention of an acute
admission or transfer from the physical care wards
where they were no longer appropriately placed.
Conclusions
We conclude that delayed discharge is a problem for
older inpatients with mental health problems. While
the British health framework and changes were what
originally sparked our interest, the results have
international implications with discharge, as there
are similar difficulties in other countries (e.g. Draper
& Luscombe, 1998). The possibility of new funding
for intermediate care is an opportunity to turn this
problem around. Already in some areas patients with
mental health problems are excluded from IC
(Baldwin, 2003). Our study indicates that this is
inappropriate. It will require an initial injection of
resources but should enable services to reduce
excessive and inappropriate spending on acute
in-patient care. Intermediate care should help the
development of seamless service provision. These
new services will require evaluation. Intermediate
care will not be a panacea and has potential problems
but seems a better solution than the present system.
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