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Intermediate Care and Reablement in Domiciliary Support (Wales) Policy

Introduction

Intermediate care and reablement includes a range of services potentially available to older people who are leaving hospital and to older people who are at risk of hospital admission. The emphasis of intermediate care and reablement is on promoting independence through active recovery as it aims to help to move a person receiving care from medical dependence to being more independent by providing a supported pathway between social, primary and acute care. The aim is to avoid unnecessary or inappropriate hospital stay.

It is recognised that intermediate care can be provided in a range of settings, ranging from hospitals to care homes to people’s own homes, and that intermediate care is only appropriate where older people are medically stable and no longer need specialist medical support on hand. People living with dementia are not excluded from receiving intermediate care where it is indicated.

The two forms of intermediate care that could involve a domiciliary care service are:

• crisis response in which the agency might be contracted into by forming part of a crisis response team
• reablement in which the agency would again be contracted into to contribute to the work of the multidisciplinary teams providing reablement services.

Policy Statement

This policy sets out the values, principles and procedures underpinning {{org_field_name}}’s approach to its intermediate care or reablement service provision (where applicable). It is in line with the requirements of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 as they apply to this specialist form of service provision.

The policy seeks to:

• establish clarity of roles and expectations between the service and intermediate care purchasers
• ensure that it provides a high-quality, safe and appropriate service with areas of risk addressed
• provide the basis for a sound contractual agreement which delivers value for money
• provide a service that is consistent with the intermediate care provisions set out in the Social Services and Well-being (Wales) Act 2014.

Home-based Intermediate Care and Reablement

The service recognises that home-based intermediate care:

• is targeted at older people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long-term residential care, or continuing NHS in-patient care
• is provided after a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery
• has a planned outcome of maximising independence and typically enabling people receiving care to resume or remain living at home
• is time limited (normally no longer than six weeks and frequently as little as one to two weeks or less)
• involves cross-professional working, with a unified assessment framework, single professional records and shared protocols.

Principles and Procedures

{{org_field_name}} recognises that most reablement programmes will be planned by the multidisciplinary team responsible for developing the local intermediate care provision. For people subject to an intermediate care programme it also recognises the following principles and procedures will apply.

Governance and management

1. The agency if involved will be expected to subscribe to the local intermediate strategy and its governance and management arrangements.
2. All contracts for intermediate care will be time limited and that time should be specified at the entering of an agreement.
3. There will be locally agreed methods for recording and documentation, which agency staff involved will use and be trained to use.
4. There is likely to be multi-professional involvement in the programme to which the agency will commit in all respects, including staff training, support and supervision.
5. The agency’s staffing arrangements reflect the ethos of a person-centred, therapy led, strengths-based service and that staff have relevant experience, training and competence in reablement work.
6. The agency will be responsible for:
   – providing agreed, adequate levels of appropriately qualified staff
   – maintaining staff competences through regular training and review
   – checking that all qualified staff have current registration with the relevant professional registration bodies.

Intermediate care planning and delivery

1. The service will appoint an intermediate care lead to be responsible for organising and co-ordinating the programmes.
2. The intermediate care lead will work closely with the local area case manager/intermediate care co-ordinator (if applicable) and adult social care services to design and deliver individual programmes.
3. The needs of the person receiving care will be comprehensively assessed using locally agreed protocols to identify goals, which form the basis of the person’s care and support plan, and to identify any risks to their achievement.
4. The person receiving care will be registered with a GP, who could be their usual doctor, who should be consulted as needed.
5. No significant acute changes in medical management should be anticipated within the contracted period of intermediate care provision.
6. The assessed requirement for care must indicate that the person’s care can be safely and effectively provided outside of an acute hospital.
7. The assessed requirement for care should indicate that maximum independence is most likely and can be safely achieved with the appropriate support.
8. The person receiving care should initially be assessed as being likely to achieve their reablement goals at the end of the agreed period (usually six weeks) unless exceptional circumstances apply.
9. Care staff involved will record all work completed and the progress being made towards the care plan goals and will always be prepared to discuss issues with the other team members involved, take part in team meetings and training events.
10. Care staff involved will immediately notify their case manager or intermediate care co-ordinator in the event of a significant deterioration in a person’s health status.

Training

All staff involved in reablement programmes receive specialist training in line with their roles and responsibilities. Training will follow the National Institute for Health and Care Excellence (NICE) training and development guidelines, described in NG74: Intermediate Care Including Reablement (NICE 2017) (and equivalent guidance from Social Care Wales/NHS Wales).

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

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