1. Bed based response -information for design workshop

2. What is a bed based response?
A different type of bed base which could be smaller if supported by more intensive, flexible support in the community. This service would be for the most complex patients, providing assessment and re-enablement where it is not possible to provide this at home. A significant proportion of this bed base needs to be equipped to safely assess and meet needs of patients with Dementia, Delirium and cognitive impairment.
Key points from the review
Ideally this would be an integrated health and social care bed base. With the flexibility to meet both health & social care needs.
Mental health expertise would need to be as an integral part of the staffing 24/7
Offering short term assessment and medium term interventions.
Access would be via the same single point of access and assessment by the community IC service so people are admitted only when it is not possible for them to support someone at home.
In-reach by community IC service into the bed base to facilitate discharge and support patients in their own homes ASAP.

3. National guidance/ evidence base (bed based)
The last policy guidance specifically for intermediate care services was published by the Department of
Health in 2009 (Intermediate Care – Halfway Home Updated Guidance for the NHS and Local
Authorities). It suggests that the core intermediate care service should generally be provided in community-based settings or in the person’s own home, but a range of services is likely to be needed, including bed based services. Some beds may be provided in care homes
In some areas the service might be able to manage with fewer beds if it employed more
24-hour community-based staff.
Specialist beds may be designated for people with mental health needs and Dementia and it is also important to have access to community psychiatrists and to liaison teams working in acute hospitals.
Most of the relevant guidance published since this time has been about developing non -bed based models.
The evidence for the effectiveness of residential nurse-led units or nursing home based intermediate care is limited. While they may be safe and effective, they may also be inefficient.
Community hospitals have been found to be a more effective setting for rehabilitation of older people following an acute illness than acute hospitals, although the costs were similar.
Avoiding hospital admissions-What does the research evidence say?
Sarah Purdy. December Kings Fund
Intermediate Care – Halfway Home Updated Guidance
for the NHS and Local Authorities 2009

4. Number of beds.

5. Examples of good practice
Who else is doing it?
Examples of good practice
Leeds Community Beds- Plans for them to be a key part of neighbourhood teams, flex around patient need. Social care beds with mental health & Dementia trained staff and access to other specialist input as needed.
community-beds-V2-FINAL pdf
Health-Social-Care-Integration-Integrated-James-Woodhead.pdf
Norway IC hospital- 12 beds co-located with primary health care services. Hospital is 50km away. Develop integrated care pathway for elderly & chronically ill patients; Provide an arena for professional collaboration between hospital and primary health care. Staffed by Nurses, OTs, Physio’s and GP’s.
Greenwich Intermediate Care 12 bed unit – Nurse led service includes OT, Physio Psychiatrist, Geriatrician and GP, provides rehab when recovering from physical & mental illness.
International Psychogeriatrics, 25:6 page
Full text available ProQuest at international Psychogeriatrics (12 September 2014).

6. Who needed a bed based response?
Age- Tended to be slightly older than other responses 54% were over % were over 90. Home situation-73 % lived alone (almost 10% higher than other responses). Only 8% were living independently prior to this episode. 52% had some form of care package or regular health intervention, again more than other responses. 38% were managing with regular support from friends and family. Long term conditions (LTCs) - 84 % required monitoring of chronic illness or LTCs. 24% required regular interventions as a result of LTCs and 3% more frequent interventions. Dementia/ Cognitive Impairment-Those who needed a bed based response were more likely to have a diagnosis of Dementia or cognitive impairment prior to this episode than other responses (22%- Dementia 15% Cognitive Impairment) and on assessment over 50% had needs around memory, cognition and confusion. For 32% this was a high or very high level of need. 16% had come into services due to a local infection and for some this was the cause of the confusion and delirium so a bed based service was needed while this resolved. Communication was often difficult for this group of patients as a result of their confusion. Mental health, behavioural symptoms and risk-14% had a mental health diagnosis prior to admission and 25% had current support needs related to their mental health or behavioural symptoms, which is much higher than other responses. A quarter had significant risk issues or there were safeguarding concerns (25%). Mobility- more likely to have needed a walking aid prior to this episode and on referral just under half needed supervision, another 28% needed physical assistance, while 9% were not mobile at all. Falls- 76% were a falls risk and for 40% a fall was the reason for this episode of care, with half of those having had a fracture as a result of the fall (20%). There was also a slightly higher incidence of Osteoporosis in this group than others. Nutrition- 27% of the sample needed nutritional monitoring or referral to a dietician and the same percentage also needed support, prompting or physical assistance with feeding and drinking. Continence- 38% had continence needs, double the number in home based responses. Informal Carers- 80% had an informal carer and where identified over half needed formal carers support and 11% were unable to cope or needed their own support package.

7. What types of interventions were needed?
(bed based response)

8. What types of interventions were needed?
(bed based)
Medical investigations included…
Blood tests/ U&Es
Review of mental health
Repeat scans, tests
Clinical interventions identified were…
Pain management/ relief
Nutritional monitoring
Wound care (including surgical wounds)
Pressure areas
Antibiotics (oral and IV)
Observations
Catheter care
Monitoring while commencing new medications
Bowel management
Other types of interventions…
Continence assessment
Behavior management
Assessing self medication/ medication compliance and setting up NOMADs
Care planning for the future
Liaison with other services and referring on.
NOT COMPLETE
Reablement included…
Supported ADL practice
Assess impact of confusion on daily living.
Develop strategies to adapt cognitive impairment and manage risk.
Practice mobility, stairs, transfers
Prompting (to take meds, to eat, to maintain hip precautions, do exercises etc)
Support family/ informal carers
Assess need for ongoing support.
Rehabilitation included…
Rehabilitation after surgery

9. What types of interventions were needed?
(bed based)
Assessment for long term care
Reablement
Needs supervision when mobilising
Need assistance to mobilise
Not mobile
24 hour supervision
24 hour carers
24 hour nursing intervention
No Cognitive Impairment
Mild cognitive impairment/ confusion
Cognitive Impairment- Medium need
Cognitive Impairment- High or very high needs
Safeguarding/ risk issues
Less complex need
More complex need
More independent
More dependent

10. Who is needed to deliver them?
Most frequently identified
Occasionally identified
Medical/ clinical review
GP and Geriatrician (equal split)
Dietician
Psychiatrist
Specialist team
(Parkinsons, Orthopaedics etc)
Medical investigations
GP / Geriatician
OPMH
Specialists
Medication review
Geriatician GP
Nurse prescriber
Pharmacy
Regular clinical interventions
Nurses
OPMH Nurses
Specialist nurses
Mobility/ transfer assessment
Physio
Therapists
Reablement
Therapy/ reablement workers
OPMH/ reablement workers.
Reablement workers
Rehabilitation
Functional / ADL assessment
OTs
Therapist
Capacity Assessment
Social care
MDT
Comprehensive Geriatric Assessment
Geriatrician
Psychological support / counselling
Counsellor/ IAPT type role
Wellbeing workers
CVS
Falls assessments
Safeguarding assessment
Social Workers
Assessment for long term care
Social Care
Health and social care
Carers support
CVS/ social care
Dementia Navigators

11. What patients told us…