Intermediate Care is part of a complex system of health and
social care delivery which involves integrated working between NHS
commissioners, acute trusts, social care, providers and the
voluntary sector. This service has developed over a number of years
and requires a more integrated approach in Sefton to improve
outcomes for organisations and customers alike.
National Service Framework for Older People
The aim of Intermediate Care in the National
Service Framework for Older People 2001 is:
‘To provide integrated services to
promote faster recovery from illness, prevent unnecessary acute
hospital admissions, support timely discharge and maximise
The focus is on 3 key
- Responding to or averting a crisis including the need to
prevent avoidable hospital admissions;
- Planning Active Rehabilitation at the earliest opportunity
following an acute hospital stay;
- Preventing unnecessary or premature admission to long term
Intermediate Care provides an opportunity to
maximise an individual’s level of physical functioning, to rebuild
confidence and to restore the skills needed to live safely and as
independently as possible.
This is achieved by:
- Having timely access to information and services;
- Receiving a holistic assessment of needs (including
- Following agreed Care Plans to support individual goals
- Effective coordination of service delivery.
Key elements of Intermediate Care in Sefton
- Intermediate Care is available to people aged
18 and over (although the main user group tends to be older
- The service can deliver the following: i)
early intervention and prevention, ii) maintaining self care and
independence and iii) meeting complex needs in a timely, flexible
way, closer to home.
- Key aims include maximising independence,
helping people remain at home for as long as possible (with or
without support), reducing inappropriate hospital re/admissions,
reducing the length of inappropriate stays in hospital, supporting
timely and safe discharges from hospital and other rehab
- The focus for rehab and intermediate care can
include support for people who; have experienced falls, have a
short term illness, are recovering from injury or surgery, are
suffering from reduced mobility and ability to self care, are
experiencing exacerbations and deterioration in health due to long
term health conditions, are considering long term residential and
nursing care etc.
- The type of resources used can include;
community teams, specialist teams, domiciliary support, telecare,
equipment and minor adaptations, day care, day hospital, assertive
outreach, residential care, nursing care and hospital
- The workforce can include; consultant,
general practitioner, nurses, community matrons, occupational
therapy, physiotherapy, psychology, social work, speech and
language therapy, dietetics, podiatry, therapy and re-
enablement assistants, care assistants, voluntary sector
- By reducing the points of access to
intermediate care and by developing single assessment we are hoping
to improve the cycle of advice, information, assessment,
investigations, treatment, care planning, review, reassessment and
onward planning, support.
- The timescale for services tend to be short
term in nature. A new target for community services is 19 days. For
this period of time services in relation to intermediate care are
- If longer term support is required charges
may apply to services usually related to Local Authorities. There
is also a need to meet the national Fair Access to Care Services
(FACS) eligibility criteria.
- We aim to achieve better outcomes, through
seamless pathways across organisations.
- To assist step/up down arrangements are in
place and support the interface with a number of general and
specialist services across health and social care.
A Guide to Caring for the Community
Adult Social Care Department also produce a booklet 'A Guide to Community
Services for Adult in Sefton,'
which provides information
about a range community services to support you to live
independently, as well as details of residential and nursing
homes and home care providers in Sefton.
Last Updated on 4/26/2013