How intermediate health and social care services enable better care closer to home

The report suggests when and for which types of patient such arrangements are likely to be more effective, and concludes that service users, carers and professionals must plan care together for successful outcomes.

Health systems in all developed countries continue to grapple with the joint challenge of reducing the use of costly hospital care and meeting people's preferences for care in the community or in their own homes. Models of 'intermediate care', which allow people to leave hospital earlier or avoid admission in the first place when faced with a health crisis, have been a major response to this challenge for people with a variety of conditions and care needs. But they are extremely diverse in their design, actual operation and effectiveness. A report by a team of researchers at the University of Exeter Medical School has used published evidence to develop a more coherent definition of intermediate care, based on how it is believed to work. The report's findings have already attracted interest from the Community Therapists Network and others working at the forefront in health and social care.

Their report, "Intermediate Care: a realist review and conceptual framework," which has been published today on the website of the National Institute for Health Research Health Service and Delivery (NIHR HS&DR) programme,1,2 shows that the defining features of intermediate care – and also the main ones from which patient and carer benefits are believed to arise – are: the objectives and place of care are negotiated between the service-user, carers and health and social care professionals; both carers and professionals foster the self-care skills of service users, and shape the social and physical environment to 're-enable' service users, and; all (i.e. service-users, carers, and care professionals) actively contribute to decision making and the delivery of integrated care. This definition can incorporate but also transcends previous commonly used service labels, such as hospital-at-home and early supported discharge.

The review was conducted by a small team in the Peninsula Technology Assessment Group, which specialises in the synthesis of research evidence to inform policy and practice. Dr Mark Pearson, the lead reviewer, said: "By being grounded in evidence of about how models of intermediate care are thought to work, we hope it will be of more durable and practical use to managers and commissioners of such services in the future. In particular, rather than seeking any singular conclusion that intermediate care either is or is not effective overall, our review methods have allowed us to detail some of the specific circumstances and types of patient for which such service arrangements will probably be more effective, or in which they are less likely to be successful."

"It is clear from our review of the evidence that intermediate care achieves the best outcomes for individuals and organisations when it is based on genuinely collaborative decision making involving service-users and their carers. Certain higher need groups, such as those recovering after stroke, may be better able to benefit than others with more complex conditions. Conversely, for particularly vulnerable elderly patients the ideal of collaborative and inclusive decision making is more difficult, and must be balanced against care professionals' duty of care and advocacy roles."

Dr Rob Anderson, the principal investigator, added "This work broke into new territory for our team, both in terms of trying to explain variation in the effectiveness of models of care delivery – as opposed to new drugs or health promotion programmes – and methodologically, using the novel approach of realist review. We learnt a great deal in both directions, especially through having valuable input from our co-investigators Prof. Sasha Shepperd [University of Oxford] and Prof. Ray Pawson [University of Leeds]."

More information: Pearson, M., et al. Intermediate care: a realist review and conceptual framework. Final report. NIHR Service Delivery and Organisation programme; 2013. www.netscc.ac.uk/h… f=10-1012-07

Provided by University of Exeter