The journey to intermediate care in a care home

Context

Wheatlands is a care home in Bonnybridge, Falkirk with 59 rooms. At the time of this project, the home was at full capacity with a waiting list, but wanted to do more for the local community. There are also two General Practice surgeries located conveniently on Wheatlands’ grounds as well as access to the local community within easy walking distance. The management at Wheatlands has recently invested in the home by building a galley kitchen for residents who wish to cook independently as well as a sensory garden with chickens. Wheatlands care home has a philosophy of enablement that is an integral part of their operations, and is something in which the management and staff take great pride. Wheatlands care home is owned by the Balhousie Group which has experience in intermediate care and alternative models of residentially based support in Scotland.

The opportunity

Wheatlands care home has a small disused cottage in the grounds which had fallen into disrepair. At an office Christmas party, the manager was inspired to do something with that space and wondered if it could be renovated into two small, self-contained flats. Wheatlands considered this space could be used for respite or a space for visiting families to stay but eventually settled on using the cottages for intermediate care.

The vision

Wheatlands’ manager imagined a step up/step down intermediate care service which would support older people in Falkirk to avoid emergency hospital admissions where possible, and to be supported to get back to their best once they had left hospital. The function of Intermediate care is to integrate, link and provide a transition (bridge) between locations, between different sectors and between different states. In this case, the service aimed to provide support in the transition from hospital to home.

The vision for the facility was two accessible, self-contained flats each with a bedroom with en-suite, living room and kitchen. The flats would provide a homely setting in which older people could regain independence and skills before they move back home.

The service would have access to a variety of resources within the home including:

• 24 hour access to nursing support
• Night support if needed
• Access to facilities including cooked meals if needed
• Peer support and socialisation
• A private garden
• The cottages would also have links to the community and to community teams like:
• ReACH Team (Falkirk reablement) with one full day each for an Occupational Therapist and a Physiotherapist to be stationed in the care home to plan and support the transition home
• Access to the local GP clinics on site
• Access to the local community

Proposed Outcomes

We hoped that the introduction of this service would improve Falkirk’s Emergency Admissions and Delayed Discharge rates. We also hoped that by introducing the service, independent care homes could take on more of a role in delivering more than just residential support.

What did we do?

The Fit for the Future project worked closely with Wheatlands care home to develop their vision for the cottage and work with the partnership to source funding for a small ‘test of change’ to see if the step up/step down service could deliver outcomes for older people in the area.

Who was involved in this process?

• Balhousie Wheatlands management
• Change Fund Team
• Falkirk ReACH (community reablement) team
• Scottish Care
• Iriss

What worked?

• Integrating the proposal with Falkirk’s ReACH Reablement team to form an integrated approach to supporting transitions, both in the care home and the community. Initially, the ReACH team was not involved with the proposal, but having their support made the service concept much more robust, and led a better whole systems understanding of where the gaps were.

• Building on existing staff skillset and values and ‘notching up’ the processes and relationships to support these. This process was supported by the experience of one resident, Jim, who used all of the resources at Wheatlands to meet his outcomes and live an independent life in the community. You can see Jim's story here.

• Learning from other projects in the area. In particular, a key learning point from an already established intermediate care service was that the eligibility criteria should be as clear and open as possible, as they were having issues with under-referral and inappropriate referrals more generally.

• The group took the decision to make the referral process easier by basing the criteria of entry on eligibility rather than ineligibility. For example, it does not exclude people who live with dementia because Wheatlands believes that this does not make someone unsuitable for reablement.

Step Up/Step Down Eligibility Criteria

• Reablement is possible and feasible within the maximum eight week timescale (decided by pre-assessment and existing information)(as above)
• An individual who is unwell and requires care and support but not necessarily a hospital admission, doesn’t stay in hospital unnecessarily and block a bed
• No palliative care
• Experienced a fall, stroke, TIA, chest infection, UTI, fracture, delirium, a wound that affects mobility but will be able to go home after a period of maximum eight weeks
• Open to people with dementia who meet the reablement criteria, the service would liaise with the Dementia Link worker or CPN to ensure that a reablement service would be in the individual’s best interests.

What were the challenges?

There were ongoing delays in partnership communication, issues in feedback and misunderstandings with the Joint Management Group who are responsible for allocating Change Fund monies and overseeing Reshaping Care projects. The project hoped to use Change Fund monies to pay for the initial renovation and fund the service for a year to test whether it produced meaningful outcomes for older people and the partnership more generally. However, there was back and forth on whether there were sufficient change fund monies available, and a refusal to fund the capital investment. Following this, Wheatlands agreed to pay for the renovation themselves and ask only for a year’s funding of the service and for time from ReACH team physiotherapist and occupational therapist. This proposal was submitted to the Joint Management Team three times, and each time met very limited deliberation. Throughout this project there was a lack of communication, and after the first submission the provider waited several months before hearing that the proposal needed to be resubmitted. These delays led to more strained relationships and a loss of initial momentum.

There was a challenge in balancing the risk of investment for the provider against unsteady future funding/commissioning from the local authority. The onus was on the independent provider to shoulder the risk of investment in the property despite the proposed benefit to the local authority. Wheatlands was in a favourable position in that they had a waiting list and could justify the risk by having secondary plans to repurpose the flats into respite.

How far did we progress?

At the end of the Fit for the Future Project’s involvement, the proposal for the intermediate care facility had still not been funded. A series of delays and misunderstandings from the Joint Management Group about the availability of funds, and the feasibility of the service meant that the proposal was submitted on three different occasions but was neither accepted nor rejected. The group remains hopeful that there will be an opportunity to make this service a reality. Despite the difficulty in getting this project off the ground, the process has helped Wheatlands begin to plan for the future, and to position itself as a creative provider. The project has also helped us learn about the difficulties in supporting the independent sector in becoming more creative, proactive partners in joint commissioning.

Three Lessons Learned

• The process of developing a new service can be significantly delayed by bureaucratic processes and these delays do not best serve the community. More joint working and open communication is needed for the joint commissioning partnership to begin looking at solutions together and view each other as equals.
• Care homes are capable of delivering reablement for older people in the community whether or not they are especially commissioned to do so.
• The independent sector can be proactive and creative rather than just reactive, and sometimes, this effort is not recognised.

References

Scottish Government (2012) Maximising Recovery, Promoting Independence: An Intermediate Care Framework for Scotland