Intermediate care: a stepping stone from hospital to community

How a multidisciplinary service is tackling the costly problem of delayed discharge

How a multidisciplinary service is tackling the costly problem of delayed discharge in England, Scotland, Wales and Northern Ireland

The problem of patients remaining in hospital after their immediate medical condition has stabilised is not new, but despite efforts to reduce these delayed transfers, they have been on the rise.

Register manager Jordan Pereira with patient Fay Crookes at Grove Discharge Unit, an intermediate care service operated jointly by Four Seasons Health Care and Wirral University Teaching Hospital NHS Foundation Trust

In 2016, an independent report for the Department of Health by Lord Carter of Coles estimated that on any given day as many as 8,500 beds in acute English trusts were occupied by patients who were medically fit and could be transferred. The annual cost of these delayed discharges to NHS providers could be as much as £900 million. 

Knock-on effect

The delays also have a knock-on effect resulting in cancellations of elective operations because of a lack of bed capacity and work going to the independent sector.

In English acute hospitals, bed occupancy has remained above the recommended maximum of 85% since 2012-13 and from January to March 2017 it was the highest ever at an average of 91%, according to the Care Quality Commission.  


The amount of beds on any given day in acute English trusts that are occupied by patients who are medically fit and could be transferred

Source: Operational Productivity and Performance in English NHS Acute Hospitals: Unwarranted Variations 

Most of the patients who are affected by delayed transfers of care are older people waiting for appropriate packages of care to allow them to be discharged. The NHS recognises that delayed discharge puts patients at risk of infections, depression, loss of independence and confidence, as well as being an inappropriate use of NHS resources.

Increasingly, clinical commissioning groups (CCGs), local authorities and independent care providers are working together to provide intermediate care solutions to alleviate the problem.

Complex needs

Intermediate care is a multidisciplinary service providing support and rehabilitation to people whose condition has stabilised, enabling their transfer from hospital to the community or avoiding unnecessary admissions.

Four Seasons Health Care is part of a joint initiative involving CCGs and local authorities. It has 14 intermediate care services across England, Scotland, Wales and Northern Ireland. Unlike conventional care homes, these centres are dedicated to the intermediate care of patients who often present with complex needs. Their clinical teams may include nurses, matrons, physiotherapists, occupational therapists, social workers and carers, along with GPs on call.

Managing the care pathway

The service manager and clinical lead, who typically would both have a nursing background, work proactively with trust and community multidisciplinary teams (MDTs) to manage the care pathway. They are the first point of contact for patients, their families and carers when they arrive at the service and they plan for patients’ discharge and ongoing support together with external health and social care professionals.

The intermediate care unit leader, who would also be a nurse, is responsible for care standards and supervises two intermediate care sisters.

Ward manager Filipa Andrade and 
healthcare assistant Janet Cantrell (right)
help Alex Barnes to mobilise after
having a cast removed

A technology-enabled intermediate care support framework developed by the company equips its centres to provide a consistent standard of service, which is compliant with the National Institute for Health and Care Excellence guideline for intermediate care and aligned to intermediate care policy drivers, such as the NHS Five Year Forward View and the 2017 national audit of intermediate care in England.

The framework enables nurses to carry out digital audit and tracking of each patient’s condition and needs and an electronic dashboard gives real-time data readouts. The technology can be used to provide performance and outcome measures to help show the difference the service is making to the local health system.

Improved patient flow

Where intermediate care has been introduced and properly implemented it has proven to be an effective model that works well for patients and the health service. Hospitals free up beds in acute wards, improving patient flow through the system, and patients are given the therapeutic interventions they need in a more comfortable place.

The 2017 national audit found that the experience of intermediate care service users was generally positive with all aspects of the services gaining high results using the patient-reported experience measure. More than 91% of people felt they had been treated with dignity and respect. From an open narrative question, the most common source of praise was staff attitudes and ‘receiving good service or care’. The average length of stay in our centres is 25 days with 70% of patients able to return home afterwards and 93% maintaining or improving their dependency level.

Although the primary purpose of intermediate care is to alleviate the problem of delayed discharge from hospital, there is also a cost-saving benefit to the NHS.

£900 million

Estimated cost of delayed discharge to NHS providers 

Source: Operational Productivity and Performance in English NHS Acute Hospitals: Unwarranted Variations 

Targeting delayed discharge

Intermediate care may be commissioned and paid for by a local authority to assist in enabling discharge of people from hospital into the community and to avoid possible penalties for causing delays. Sometimes the authority will commission intermediate care services to deliver reablement and will pay for it from its Better Care Fund allocation, as part of discharge-to-assess arrangements. In doing so, the authority is meeting the intended aim of closer working between health and care services. Alternatively, the CCG will commission and pay for the intermediate care service to free up hospital beds and because it makes economic sense.

Resilient support for the next step

Staff nurses Kate Williams and Naomi Davidson (right) with patient Raymond Salisbury

Key external relationships are important at all stages of the process. The teams deliver intermediate care work with extended MDTs in the hospital and the community, ensuring robust pathways into the service and resilient support for the next step after being discharged from it.

While home-based care is the least expensive, there is a growing evidence base to suggest that intermediate care can result in better outcomes. According to the 2017 audit, for home-based care dependency was improved for 72% of patients, maintained for 21% and deteriorated for 7%. However, for bed-based care, as found at intermediate care centres, dependency was improved for 85% of patients, maintained for 8% and deteriorated for 6%.

In many cases, patients who transfer from an acute ward to an intermediate care centre could not be cost-effectively supported in their own home straight from hospital and the intermediate care centre is a stepping stone on their care pathway. That next step may well involve a package of home-based care.

Despite the benefits to NHS providers and patients, intermediate care services are still used on a relatively small scale. With an ageing, more complex and dependent population set to grow in the coming decade, the need to expand these services has never been greater or more urgent.

A patient’s story

After a six-week stay in hospital, a 71-year-old patient was admitted to Green Lane intermediate care centre in Leeds. Before admission to hospital, she had been living alone in her own house independently.

On admission to intermediate care she weighed 82kg, which was 6kg below her normal weight. She had severe bilateral leg ulcers, poor food intake and low mood, exacerbated by being self-conscious about odour from the ulcers. She did not readily engage with staff because of her low mood.

The intermediate care nursing team got to know the patient so they could understand her needs and preferences when drawing up a plan of care with her. The aim was to return her to her baseline mobility and independence. In doing so they began to develop a therapeutic relationship.

The patient’s leg ulcer was managed with regular dressing changes and additional changes if deemed appropriate. The tissue viability nurse offered support and advice about specialist wound dressings. The odour significantly reduced as the ulcer healed.

To reverse the patient’s weight loss, the kitchen staff prepared a diet profile based on her preferences and nutritional requirements, with various choices on the daily menu. She was encouraged to eat with other patients in the dining room as a social occasion, rather than staying in her room. As the ulcer healed and the odour went she became confident to socialise and this helped to improve her mood. She began to gain weight, which was 83kg on discharge from intermediate care. 

Staff learned that she liked poetry and crocheting and they encouraged her to take up these interests. She asked family to bring in her wool and crochet hook and she began making baby blankets, which the family said she had given up doing.

These strands interlinked as a holistic approach and together they helped the patient’s journey to well-being and discharge home after 44 days of intermediate care.

About the author

Alana Irvine is intermediate care services director, Four Seasons Health Care

Further information

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