Intermediate care can not work

1. Intermediate care can not work Dr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.com

2. Outline • Linguistic, philosophical considerations • Consideration of clinical problem faced • Discussion of the solution needed • Demonstration that • the introduction of intermediate care was irrational and causes confusion • rehabilitation, in contrast, is rational, works, and fulfils the clinical need

3. Intermediate “Coming or occurring between two things, places etc.” “Occurring or coming between two points in time or events” OED 2004

4. Care “Burdened state of mind arising from fear” “Serious or grave mental attention” “Used of destitute ... who is judged fit for official guardianship” OED 2004

5. Intermediate care “A range of services at the interface between secondary care and primary care” “.. Intended to reduce avoidable hospital admission .. Improve transition from hospital to home.” From Steiner & Walsh RCT (BMJ 9/3/05)

6. Intermediate care definitions • May focus on: • Stage in a pathway • Degree of expertise • Quantity of resources • Location of service • Intention of service There is no useful definition Melis et al BMJ 2004;329:360-361

7. Does intermediate care work? • Depends upon expected outcome • Only trial • No major benefit • Costed more Walsh et al, BMJ 2005;330: (9th March)

8. Can intermediate care work? • In the absence of any agreement whatsoever about the meaning of IC, and • With different people and organisations including and excluding different things • It is not possible to conclude that it works • Because some people will say that something that is not IC is in fact responsible

9. Problem faced • Intermediate care was a politically driven solution to the (perceived) ‘problem’ of mainly elderly people staying in acute hospitals longer that some doctors and managers liked (and often the patients also wanted to move on) Need to consider nature of illness and health care systems

10. Four Levels WHO ICF model of illness Three Contexts Within body Well-being Organ (pathology) Personal Choice Person (impairment) Physical Person in environment Behaviour (activities) Body & physical environment Social Person in society Social position (Participation) Person and social environment

11. The (health) management cycle Collect data; assessment, diagnosis Patient presents Goal setting Actions Re-enter more data patient environment Treatment Support Reassess; compare with goals Exit rehabilitation/medical management

12. The (health) monitoring cycle Patient no longer has active treatment needs • Identify: • likely signs of change • likely speed/timing of change Likely to change? Yes No • Consider best method & • timing of data collection: • Post • Telephone • Visit at home • Hospital visit No Collect data Change needing input? Yes Re-enter rehabilitation No active monitoring; patient given contact details

13. Aims of health care system? • To maximise social participation of patient • maximise role function • maximise social status • To maximise well-being of patient • somatic and emotional • achieving satisfaction (adaptation) • To minimise stress on & distress of relatives • somatic and emotional

14. Major objectives of health care • Ensure that pathology is identified and any specific treatments given Then • Maximise or optimise the patient’s • Behavioural repertoire (their activities) • Ability to adapt to changes in life circumstances • Environment (physical and social context) • Minimise the patient’s distress • Minimise carer burden

15. Hospital care • Focused (increasingly) on • Pathology • Diagnosis (assessment, investigation) • Treatment (surgery, drugs) • Monitoring (usually out-patient) • Physiological (bodily) support • ITU etc • Processes are largely • Short-term, quick • Independent of context

16. Hospital care and activities • Necessary support is given • Toileting, feeding, washing, dressing • Context (environment) is hostile • Physically, socially, personally • Minimal effort to help recovery • Therefore left with a patient who cannot go home

17. What process is needed? A problem-solving process Focused on activities • Assessment (diagnosis, formulation) • identification and analysis of problems • Goal setting • Interventions that are characteristically • multi-focal, and • spread over-time • Reassessment (monitoring)

18. WHO ICF Rehabilitation Analysis of illness Within person invisible Personal context Organ (pathology) Person (impairment) Physical Context Person in environment Behaviour (activities) Within person invisible External Independently verifiable Choice Person in society Social position (Participation) Social Context Within society invisible

19. Structure needed • A multi-disciplinary group of people who: • work towards common goals for each patient • involve and educate the patient and family • have relevant expertise and knowledge • can resolve most common problems In other words, a specialistteam

20. Characteristics of service • Patient’s disease is not the focus of action • Acknowledges importance of patient’s social roles • Emphasis on minimising stress/distress • Consideration/involvement of family • Multiple interventions & coordination • Expertise and specialisation • Presence of longer-term goals

21. Note • No mention of • Location • Management organisation • Specific professions • Timing/phase of illness • Amount of resources

22. Note - 2 • Structures are inclusive • Processes are generic • Outcomes are broad • Name for this service is R E H A B I L I T A T I O N

23. And Rehabilitation does work

24. Evidence • Spinal cord injury success • Systematic reviews and meta-analyses • Stroke, multiple sclerosis, head injury etc • Randomised, controlled studies • Large parallel groups • High level aspects • Single case, case series • More detailed aspects • Controlled clinical trials (CCTs)

25. Evidence • The evidence supports the process, and says less about content • Features: • Expertise & specialism • Problem-solving, educational approach • Co-ordination • Multi-professional • Involvement of patient & family

26. Rehabilitation • Is intermediate illness management • Between • Pathology and person • Hospital and home (and work) • Beginning and end • Health and other agencies

27. Rehabilitation Clear definition of structure, process and outcome Not defined or characterised by: Location Staffing, resources Organisation Time Age/disease Intermediate care No agreed definitions Variably charact-erised by: Location Staffing, resources Organisation Time Age/disease

28. Two other differences • Intermediate care • is politically defined and driven • has no underlying logic or model • Rehabilitation • is clinically defined and driven • is logically consistent and grounded in a coherent, agreed model

29. Conclusion - 1 • Intermediate care should be abandoned • A political chimera, varying with circumstances • Not coherent, and causes confusion • Does not uniquely satisfy any clinical need • Unsupported by the limited evidence available (1 trial)

30. Conclusion - 2 • Rehabilitation should be embraced • Clinically relevant • Grounded in a logically coherent model • Strongly supported by evidence

31. Rehabilitation does work Dr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.com