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Intermediate Care in Leeds

Background

Network Data Lab in Leeds has conducted research to understand the characteristics of users of step-down intermediate care and to explore the role of the IC in effectiveness of reduction of hospital readmission.

Original Questions to look at:

  1. Definition of the users of step-down intermediate care in Leeds
  2. Understanding health care provision and demand for users of step-down intermediate care
  3. Understanding relationship of step-down IC personal, health characteristics at the risk of hospital readmission.

Data

Leeds Data Model (shared integrated care record) was used. Patients who were discharged from hospital between April 2022 and April 2023 were identyfied. The study examined 53,323 admissions involving 38,970 patients.

What did we find out?

The headlines

  • only 10% of patients after planned hospitaladmission received intermediate care.
  • there are more females and white patients that use step down IC.
  • patients from Asian backgrounds received majority home-based services: a very small number of Asian patients were discharged to rehab centres (this may be because of community and family support).
  • 33% of patients receiving IC are from deprived areas.
  • on average older patients (above 80 years old) receive reablement at home or stay in rehabilitation centres: this group of patients is also frail.
  • younger patients (average age 75) received community home-based services (neighbourhood teams, stroke, respiratory management, virtual ward, antibiotics)
  • receiving IC at home is much shorter than in the rehabilitation centre (20-30 days compared with 50 days on average)
  • patients who are referred to the IC then have a stay in hospital and then return to IC are known as receiving "continuity of care" this means they receive long-term step down IC resulting with 40 days of the stay between hospital stay.
  • home-based services take the longest time for first contact (5 days on average)
  • patients who already receive ongoing care are contacted faster than new referrals (2 days on average)
  • people with dementia who need IC are more likely to receive support at home after hospital discharge (caveat: there was limited access to bed case data).
  • 25% of IC patients were readmited to hospital within 30 days from IC.
  • 50% of resdmited patients were readmitted while in intermediate care.
  • men are more likely to be readmitted within 30 days after being discharged from step down IC.
  • patients with multiple admissions tend to be frailer and more likely to have a long-term condition.
  • we found that patients in community-based services have a higher rate of readmission within 30 days.
  • people who used IC also used 999 calls, GP, and Emergency Department (ED) more, compared to patients who do not use IC. The main contact prior to hospital admission for IC patients was GP followed by 999.

What mattered to the patient panel from the findings?

  1. Improved Discharge Process: Review the discharge process to ensure that information of Intermediate care is explained and offered to both planned and unplanned admission.
  2. Who is offered IC? The data showed that only 10% of patients from planned admissions were offered IC. None of our patient panel was offered IC following a planned admission: why is it only unplanned patients who are offered IC?
  3. Recovery support: Ensure that people in recovery settings have access to sufficient physiotherapy sessions and stimulating activities. Patients and carers should be adequately informed about the next steps. 4.Inclusive Communication: Improve communication to ensure all patients, including ethnic minorities and those with communication needs, are informed about available services like intermediate Care. 5.Involvement of Carers: Actively involve carers in discussions and decision-making processes about post hospital discharge plans for patients. 6.Flexibility in Care Plans: Maintain flexibility in care plans to accommodate changing patient needs and circumstances.
  4. Accountability and Communication: Address concerns about accountability and communication within the healthcare system, ensuring transparency and responsiveness to patient and family feedback.