A multi-disciplinary team of NHS, Adult Social Care and third sector professionals are working with patients in care homes to help support them to regain independence and to return home.
When patients in north Cumbria no longer require the level of care that is provided in a hospital but still require rehabilitation to support their independence, they can be admitted to what is called an intermediate care bed. These are located in local authority care homes in north Cumbria.
Now North Cumbria Integrated Care NHS Foundation Trust (NCIC) and system partners have a dedicated team working with care home staff to support patients who are admitted temporarily to receive the rehabilitation and time they need to make sure they can then go home.
Steve Atkinson is the Intermediate Care Service Coordinator. He said:
“After a hospital stay many people have lost key skills which means they are more at risk of falls and accidents in the home. Some people will not be able to manage walking any distance or stairs as they used to, others might struggle with meal preparation, managing medication and to manage personal care independently. Losing your independence can be frightening and upsetting. But we know that with the right rehabilitation many people can regain their independence and go back home.
“Just in time for the NHS 75th birthday we have just supported our 75th patient! The feedback that we have had has been fantastic, people thought they would never be able to go home and we helped them make that happen. It’s hugely rewarding.”
Mrs Marilyne Harris was recently admitted to Inglewood care home after having a hip replacement at the Cumberland Infirmary.
She was very reluctant to begin with but her fears were very quickly resolved and she can’t speak more highly of the service and the staff.
She said:
“I really didn’t want to go into a care home because I was worried I would never go home. But ultimately there wasn’t much choice so I resolved to myself that this was temporary, I said I would give it a week and see how I felt – I was going to get a spreadsheet and tick off the days!
“When I got there I was shown to the most beautiful bedroom with a state of the art bathroom, it had hoists and everything – I didn’t need them but it was there for those who do which is important.
“We were looked after so well, someone kept popping in to see you to check everything was ok. Breakfast was something I looked forward to, every morning it was all set out so well – they took time to make sure it was all done properly. After breakfast I could go back to my room and then there was exercise – physiotherapy - in the afternoon, this was very much encouraged and I enjoyed it. Lunch was always very nice - the food overall was lovely - the chefs made a real effort. Everything that we did was geared to getting you better and helping you go home – at breakfast for example I was encouraged to help make toast for others that helped them see how independently I would be able to do things at home. They cleaned every day in the home and I could have visitors any time I liked. Even my grandson remarked how nice it was.
“The medical care was good too we had regular visits from the medics to check we were taking our medicine properly and if we needed any changes. When it came to the point where I was ready to actually come home I was quite nervous and scared and didn’t feel ready. The team supported me to have a home visit where I went home and they got me to do things around my own home to see how I would manage. Things like putting the kettle on and moving about in your own home, using the facilities.
“Although I was sceptical I can honestly say it was wonderful, the staff and everyone are great and they all work towards getting you independent and back to your own home. I never went to bed thinking I don’t want to be here. Now I am home I am doing really well, you soon get back into your old ways. I still have people come to my home to help me but I am back and it’s lovely.”
Previously, intermediate care beds were managed by different nursing and therapy teams. Now, one team manage all of the intermediate care beds in the care homes in north Cumbria. This is more streamlined and will improve the focus on flow – making sure patients are in the right place for their needs.
Steve explains:
“The team provides wraparound care for the patient and includes a lead occupational therapist, physiotherapist, rehabilitation assistants, discharge navigator and social worker. There is also input from the third sector including Age UK, West Cumbria Carers and iCan Health & Fitness.
“We are working closely with wards at the Cumberland Infirmary, West Cumberland Hospital and in community hospitals to identify patients who no longer need to be in hospital and are suitable for the intermediate care beds.”
Nicki Simpson, Lead Therapist for the team, added:
“We provide intensive rehabilitation work to give patients the opportunity to get back home again rather than into residential care full-time. We have a strong ethos around maximising independence and also supporting families too through the third sector partners. Although our beds are located in care homes, they are not a permanent care home bed and we work hard to create a home-from-home atmosphere to give people the best chance of getting back home safely. We are passionate about helping people to regain skills after a hospital stay.”
Steve added:
“The impact of the third sector has also been fantastic. iCan Fitness run group activities and patients love them coming in, you can see big smiles on their faces, making their rehabilitation genuinely enjoyable. Some patients are continuing to follow iCan programmes with them once they get home. Age UK have also had a really positive impact helping patients arrange shopping, key safes and meals on wheels.”
Of the patients who have been through the programme the vast majority have been discharged home completely independently or with some structured long term or short term care support. Far fewer have been re-admitted to hospital or transferred to long term residential care.