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)1865-737310Fax: +44-(0)1865-737309

email: derick.wade@dsl.pipex.com

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

Intermediate

“Coming or occurring between two things, places etc.”

“Occurring or coming between two points in time or events”

OED 2004

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

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)

Intermediate care definitions

• May focus on:Stage in a pathwayDegree of expertiseQuantity of resourcesLocation of serviceIntention of service

There is no useful definitionMelis et al BMJ 2004;329:360-361

Does intermediate care work?

• Depends upon expected outcome• Only trial

No major benefitCosted more

Walsh et al, BMJ 2005;330: (9th March)

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 worksBecause some people will say that something

that is not IC is in fact responsible

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

Organ (pathology)

WHO ICF model of illnessFour Levels

Three Contexts

Person (impairment)

Person in environmentBehaviour (activities)

Person in societySocial position (Participation)

Personal

Physical

Social

Well-beingWell-being

ChoiceChoice

Within bodyWithin body

Body & physical Body & physical environmentenvironment

Person and social Person and social environmentenvironment

Patient presents Goal

setting

Support

Treatment

Reassess; compare with goals

Exit rehabilitation/medical management

Re-enter

The (health) management cycleCollect data; assessment,

diagnosis

Actions

more data patient environment

The (health) monitoring cycle

Patient no longer has active treatment needs

Likely to change?

No

No active monitoring; patient given contact details

Yes Identify:•likely signs of change•likely speed/timing of

change

Consider best method &timing of data collection:

•Post•Telephone

•Visit at home•Hospital visit

Collect data

Change needing input?

Yes Re-enter rehabilitation

No

Aims of health care system?

• To maximise social participation of patient maximise role functionmaximise social status

• To maximise well-being of patientsomatic and emotionalachieving satisfaction (adaptation)

• To minimise stress on & distress of relativessomatic and emotional

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

circumstancesEnvironment (physical and social context)

• Minimise the patient’s distress• Minimise carer burden

Hospital care• Focused (increasingly) on

Pathology• Diagnosis (assessment, investigation)• Treatment (surgery, drugs)• Monitoring (usually out-patient)

Physiological (bodily) support• ITU etc

• Processes are largelyShort-term, quickIndependent of context

Hospital care and activities

• Necessary support is givenToileting, feeding, washing, dressing

• Context (environment) is hostilePhysically, socially, personally

• Minimal effort to help recovery• Therefore left with a patient who

cannot go home

What process is needed?

A problem-solving processFocused on activities

• Assessment (diagnosis, formulation)identification and analysis of problems

• Goal setting• Interventions that are

characteristicallymulti-focal, andspread over-time

• Reassessment (monitoring)

Organ(pathology)

WHO ICF Rehabilitation Analysis of illness

Person(impairment) Person in

environmentBehaviour(activities)

Person in societySocial

position (Participation)

Personalcontext

PhysicalContext

SocialContext

ChoiceChoice

Within personinvisible

Within societyinvisible

ExternalIndependently verifiable

Within personinvisible

Structure needed

• A multi-disciplinary group of people who:work towards common goals for each

patientinvolve and educate the patient and familyhave relevant expertise and knowledgecan resolve most common problems

In other words, a specialist team

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

Note

• No mention ofLocationManagement organisationSpecific professionsTiming/phase of illnessAmount of resources

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

And

Rehabilitation does work

Evidence

• Spinal cord injury success• Systematic reviews and meta-analyses

Stroke, multiple sclerosis, head injury etc

• Randomised, controlled studiesLarge parallel groups

• High level aspects

Single case, case series• More detailed aspects

• Controlled clinical trials (CCTs)

Evidence

• The evidence supports the process, and says less about content

• Features:Expertise & specialismProblem-solving, educational approachCo-ordinationMulti-professionalInvolvement of patient & family

Rehabilitation

• Is intermediate illness management• Between

Pathology and personHospital and home (and work)Beginning and endHealth and other agencies

Rehabilitation

• Clear definition of structure, process and outcome

• Not defined or characterised by:LocationStaffing, resourcesOrganisationTimeAge/disease

Intermediate care

• No agreed definitions

• Variably charact-erised by:LocationStaffing, resourcesOrganisationTimeAge/disease

Two other differences

• Intermediate careis politically defined and drivenhas no underlying logic or model

• Rehabilitationis clinically defined and drivenis logically consistent and grounded in a

coherent, agreed model

Conclusion - 1

• Intermediate care should be abandonedA political chimera, varying with

circumstancesNot coherent, and causes confusionDoes not uniquely satisfy any clinical

needUnsupported by the limited evidence

available (1 trial)

Conclusion - 2

• Rehabilitation should be embracedClinically relevantGrounded in a logically coherent modelStrongly supported by evidence

Rehabilitation does work

Dr Derick T Wade,Professor in Neurological Rehabilitation,

Oxford Centre for Enablement,Windmill Road, OXFORD OX3 7LD, UK

Tel: +44-(0)1865-737310Fax: +44-(0)1865-737309

email: derick.wade@dsl.pipex.com