EXAMPLES OF REHABILITATION IN INTERMEDIATE CARE:
An integrated rehabilitation service, based
in four local community settings in Halifax, ensures patients
have access to rehabilitation, including physiotherapy, in their
own homes, in local day centres and health centres. The service
also provides a residential rehabilitation unit for elderly people,
run by social services, and an early discharge rehabilitation
at home scheme.
A close partnership between the local authority,
the local primary care group and health authority underpins the
development of community rehabilitation services in the area.
Pressure on acute beds led to a project in Kettering
which helps patients who need a period of recuperation after a
stay in hospital or treatment in A&E. The majority of patients
who need this type of help are older people (the average age is
72), but people who have had an orthopaedic operation and don't
have support at home also benefit from the scheme. The project
has 10 beds in a nursing home where nursing is provided for up
to four weeks. After treatment in the unit, 64 per cent of patients
are discharged home without need of further help.
The Sheffield Assessment and Integrated Care
Unit provides elderly people admitted into A&E departments
after a fall, with a rapid response health and social service
support team. The scheme aims to provide an immediate assessment
of needs for people not requiring hospitalisation following an
acute or traumatic illness, but who do require some social care
The team liases across agencies to draw up a
package of support for each patient. Multi-agency team meetings
maintain a seamless service. Collaborative care notes are faxed
between agencies to access immediate follow on services and to
minimise duplication of patient details.
CARRIE aims to provide a seamless model of care
to elderly people, with multidisciplinary assessments, rehabilitation,
social care and crisis intervention placement at nursing homes.
When a referral is received, an assessment is made as to whether
the older person can remain safely at home. If the client cannot
cope, he/she has the option of spending up to five days (free
of charge) in a local nursing home to receive relevant medical
investigations, multidisciplinary assessments and the rehabilitation
necessary to return home. All clients receive a home visit prior
to discharge from the nursing home and the team follow up the
client at home until the rehabilitation goals have been achieved.