1. 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

2. 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

3. 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

4. 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)

5. 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)