ICF Integrated Care Pathway Workstream Intermediate Care Integrated AHP Working ICF Integrated Care Pathway Workstream Care Manager Role in Assessment and Discharges Rapid Response and Resettlement and Intermediate Care Discharges

Intermediate Care Improve outcomes for older people Reduce Older People being delayed in hospital Reduce number of Older People going directly from hospital into Long term Care Provide more opportunities for Rehabilitation and Re-ablement in a social care setting Reduce the rate per population of older people in long-term permanent care home placements Provide alternatives to admissions Develop robust and effective relationships across staff groups Support behaviour and culture change and support changes in practice Support more people to stay/ return home

Rapid Response and Resettlement and Intermediate Care Discharges Respond to referrals within 1hour Increase compliance with 4 hour target Reduce number of unscheduled care admissions Reduce discharge delays because of transport Support vulnerable patients discharged from emergency departments to get home, resettle and follow up visit if required Support 72 hour discharge Help reduce social isolation Improve partnership working Improve quality of patient experience Refer to appropriate services for ongoing support

Care Manager Role in Assessment and Discharge   Increase the number of patients seen particularly at weekends and discharged home Improving medical staff understanding of,  and interface with services provided by ECANs (Elderly Care Assessment Nurses)

Integrated AHP Working   Integrated OT/PT service with role blurring Joint paperwork to improve communication and reduce duplication Patients have speedy access to AHP and medical services in Acute and Medical Assessment Areas Streamlining pathways for Older People within acute sites Improve discharge plans for patients in downstream rehabilitation wards (e.g. discharge devolved to AHPs)