Intermediate Care / Community Reablement

Intermediate care is an NHS and Social Care programme of active rehabilitation.

In March 2020, at the onset of the Covid pandemic, the Somerset System agreed to implement a new model for Intermediate Care. This built on the Home First Model that had been operating in Somerset since 2016 and brought under one umbrella all intermediate care discharge support from hospital, as well as services to prevent admissions. At its foundation is a strong collective ambition across health and care organisations in Somerset; to maximise people’s independence and support people to remain at home as far is possible. Intermediate Care supports people to remain at home in crisis, or return home after hospital stay.  Where possible, the service will provide this support in the person’s own home.  If the person can’t be supported at home, then their recovery will be supported in an intermediate care bedded, reablement facility.  Decisions about a person’s long term care needs are made outside of an acute hospital setting. The maximum length of stay in intermediate care settings is expected to be up to 6 weeks but may be shorter depending upon how people recover. This period of up to 6 weeks is referred to as the ‘reablement period’.

People should be supported to be discharged to the right place, at the right time and with the right support that maximises their independence and leads to the best possible sustainable solutions.

Planning for discharge from hospital should begin on admission.  Where people are undergoing elective procedures, this planning should start pre-admissions with plans reviewed before discharge.  This will enable the person and their family or carers to ask questions, explore choices and receive timely information to make informed choices about the discharge pathway that best meets the person’s needs.

Under the ‘discharge to assess’, ‘home first’ approach to hospital discharge, the majority of people are expected to go home [to their usual place of residence] following discharge. This model is built on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed.  An assessment of longer-term or end of life care needs should take place once they have reached a point of recovery, where it is possible to make an accurate assessment of their longer-term needs.

In March 2023, 86% of people (aged 65 plus) were able to return home from hospital with no formal support required (i.e., a package of homecare or a placement in a Care Home).  40.1% of people were able to return home following a period of time on a bedded pathway.  Our ambition is for the proportion of people able to return home following a period of time on a bedded pathway to be as high as possible, evidencing the effectiveness of the reablement services provided by our intermediate care services.

The plates below show the transfers from our main acute hospitals Musgrove Park in Taunton and Yeovil District Hospital. During the Winter of 2022 and 2023 we supported flow by opening just over 100 additional beds due to increased hospital escalation, greater levels of Infection Prevention and Control and a weakened Home Care and Reablement workforce. This programme now needs to focus on new models and approaches to support our strategic priorities to support more people to return home.

On average our two largest acute Hospitals in Somerset discharge 2,900 people each month. Just over 13% of these people need additional support to reach their maximum potential and come to Intermediate Care for Reablement and assessment of their longer term care needs.

Our Intermediate Care Services are made up of short term home based and bed based. Our Home support service is made up of a collaboration of up to 30 Health and Social Care specialists with 7  reablement home care providers who deliver up to 2,500 hours of support each week, along with 70 nights per week to help settle some of our more complex people to settle back home. Over 75% or people supported to go home with this short term help do not need longer term care.

The Community and Voluntary Sector are also a key partner in this provision and receive up to 360 referrals each month to help people with the information and support they need to stay connected and safe in their local communities.

A key component of the Adult Social Care Strategy (2023-26) is to develop and deliver high-quality reablement services, available to all, to support people to maximise their potential and return to their optimal independence.  This will require reablement capacity to be utilised efficiently and effectively, and will support us to reduce overall system pressures providing more services within communities as opposed to within hospitals.