Scaling Up the Intermediate Care Pilots for Sustainable
Since July 2011 community staff from across health and social
care have been working together to improve outcomes for patients by
transforming intermediate care. Our 5 year vision for Adult
Community Services is that all patients who do not require
inpatient care will receive quality care outside hospital. This
vision is based on achieving year-on-year savings that can be
reinvested to further develop our services in the community. To
achieve this vision:
- Integrated teams will deliver pathways of care for chronic
- There will be an urgent community response to health and social
care needs 24 hours a day.
- There will be a range of options for the provision of high
quality end of life care which support individual choice
- All inpatients will leave hospital fully informed with ongoing
care plans once their hospital care is complete.
In year one the following new care pathways were piloted as a
first step towards this vision:
Chronic obstructive pulmonary disease
An integrated community care pathway was developed and piloted
in one GP practice to provide care for patients exacerbating from
COPD. The pathway was led by Central Manchester Active Case
Management service in collaboration with the COPD Team and the GP
practice. As part of the pilot the patients most at risk of
exacerbation were identified, joint management and assessment
documentation was used to create individualised multi-disciplinary
care plans and an integrated end to end pathway for managing
exacerbations in the community was agreed. Tele-health units have
been installed for suitable patients and work is continuing to
evaluate their use as a self management tool.
In the four months since launching the pilot, 12 patients were
assessed as high risk and given an individualised management plan.
Of these nine exacerbations were managed in the community without
triggering a hospital admission and there were four hospital
admissions which were deemed appropriate by the multi-disciplinary
team. This represents a significant reduction for this high need GP
practice in the busiest period of the year.
Funding has now been secured to upscale this pilot to all GP
practices in West Gorton and Levenshulme; 40% of Central Manchester
patients with COPD live in this locality.
End Of life
In order to increase knowledge of end of life care amongst
residential home staff, a training package has been developed and
delivered in three nursing homes by the district nurses. We are
continuing to work closely with the residential home staff to
increase the number of end of life care plans in the homes and the
number of residents who die in their preferred place of care.
Since delivering the training, seven patients have died; six of
these were able to die in their preferred place of care within the
homes. Both of these residents had an end of life care plan in
place and were cared for by the carers and district nurses in their
preferred place of care.
Funding has now been secured to increase the district nursing
service to a 24 hour service and roll out this training and support
package to all residential homes in Central Manchester.
An Intermediate Care Assessment team has been developed to
provide assessments to patients who fall in the community but do
not require treatment in hospital. The majority of referrals are
currently received by North West Ambulance Service but the
community alarms service, district nurses, active case managers,
A&E and the rapid response team can also refer.
Since January 2012 63 patients have been assessed in their own
homes and 25 have been admitted onto the home care pathway for
ongoing treatment and intervention.
Funding has now been secured to continue this pilot and to
develop urgent response pathways for other medical conditions.
Continuing Health Care
An alternative system for Continuing Health Care assessments at
the MRI was piloted aimed at making the process more patient
centred. A dedicated team including a health care worker and
a social care worker was put together to guide the patient through
the process from end to end. Results have shown a reduction
in the time taken from the beginning to the end of the assessment
process from 38 to 19.5 days.
This has now been funded and will commence once recruitment is