Intermediate care for the elderly mentally infirm

Assess

This intermediate care service, based in a community facility, was used by four different hospitals, primarily as a discharge location for the elderly, who no longer needed to stay in hospital but could not go home because they didn’t have required support. GPs could also refer patients to the service.
A number of audits had been carried out within the service, which gave helpful information, but the commissioners wanted to know more to decide if the service was effective in preventing hospital admissions or re-admissions.

See more about step 2 in the evaluation cycle: Assess

Plan

Information was captured on:

• the profile of the service users
• their length of stay
• where they had been referred from
• management of their care for the duration of their time with the service
• their destination on discharge

See more about step 3 in the evaluation cycle: Plan

Do

A lot of quantitative data was gathered from the patient records, but some qualitative data was collected through interviews with patients’ relatives.
This was analysed to produce a profile of patients who benefitted from the service in terms of an improvement in their health which directly related to their discharge destination. There was another profile of patients whose health was not positively impacted by this service.

See more about step 4 in the evaluation cycle: Do

Review and act

The final evaluation was shared in report form, and presented to commissioners and other stakeholders. The findings were presented factually, and there was acknowledgement that they would have different implications for different stakeholders.
A follow-on piece of work was discussed to set up a hospital Dementia in-reach service, to identify and plan for patients in hospital who are diagnosed with Dementia during their in-patient stay. This aimed to create a fast track for mental health assessment and appropriate discharge planning.
The discharge route for patients into the service from each hospital was highlighted as needing review, as the evaluation findings showed variation in the number of patients referred to the service from each hospital.

See more about step 5 in the evaluation cycle: Review and act