There is no ‘right’ model of intermediate care: Start with an honest assessment of your system

As the health and social care system moves out of pandemic response, system leaders are wondering what comes next. What model of intermediate care will take systems into the next phase? Our work suggests there is no single right answer but that an honest evaluation of successes enables systems to build on their strengths and develop a model that suits their population and set up.

The Discharge to Assess (D2A) model, which was made compulsory at the start of the Covid-19 pandemic, introduced a central co-ordination point (SPA) for discharges into intermediate care. The aim was to enable efficient flow and to enable reporting, with equity across the area. In a true D2A model, there is minimal assessment in hospital, and discharge into a uniform set of services. When a person returns home, their needs become clearer, and these services have the flexibility to support them. Our work suggests that, while centralised systems enable effective reporting and can build consistency, there are factors that need to be in place to make it work.

These factors include:

• Consistent services – If the D2A offer consists of a patchwork of existing services with different footprints, with staffing and operating models slotted into the new pathways, it is fundamentally inconsistent. A central hub cannot fully keep track of so many service options. Having live, accurate insight into their status is the only way to ensure effective discharge decisions are made.
• Strong relationships – Introducing a centralised SPA shifts the power and roles between individuals, teams, and organisations. Teams must trust one another and be used to working in an integrated way otherwise barriers are introduced to protect interests.
• A clear vision and culture of maximising independence – Staff need to understand why things have changed and to believe in the principles of maximising independence if they are to give up some decision-making power. This shift needs to be agreed by each member of the team to enable effective collaborative working.
• Strong communication – In a time of ongoing and shifting crisis, processes, and structures change quickly and frequently. Staff need to be kept informed to feel included in decision-making, and be able to explain to people, carers, and families why these decisions are being made.

In the absence of these factors, introducing a centralised SPA can lead to additional layers of management and process that delay discharge and disempower staff. Referrals should not have to be done multiple times. Instead, staff need to have a system in place that allows them to get them right in the first place. Without a cohesive, agreed upon discharge model, staff have to try to explain clinical decisions they do not understand. These issues can lead to a deficit-led culture where each professional focuses on building the strongest possible evidence base on why someone needs a level of support.

Where services are fragmented, more localised models can be more effective. Instead of a SPA making decisions, a wider area can be split into areas that naturally fit provision with a smaller number of options. A more localised co-ordination team can then review referrals, building relationships and a culture of collective ownership. Community services can be brought into the conversation to ‘pull out’ of hospital. Any queries can be directly followed up, in a phone conversation that helps resolve issues and build understanding, instead of an impersonal email exchange.

Different models work for different systems. However, working towards a more integrated way of working where staff are unified and patient trust is increased will undoubtedly bring benefits. The centralised D2A model has been more successful in some places than others, as you look forward, pick a model that plays to your strengths. An honest assessment of where you are as a system is a good starting point to see what might work for you.

If you want to find out more about how IMPOWER can support your organisation, get in touch.