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 [phone]
• Fax [phone]
• email derick.wade_at_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 2004329360-361

7
Does intermediate care work?

• Depends upon expected outcome
• Only trial
• No major benefit
• Costed more
• Walsh et al, BMJ 2005330 (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
WHO ICF model of illness
Four Levels
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
Support
Treatment
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

Collect data
No
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 patients
• Behavioural repertoire (their activities)
• Ability to adapt to changes in life circumstances
• Environment (physical and social context)
• Minimise the patients 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

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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
Personal context
Within person invisible
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 specialist team

20
Characteristics of service

• Patients disease is not the focus of action
• Acknowledges importance of patients 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

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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)

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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 [phone]
• Fax [phone]
• email derick.wade_at_dsl.pipex.com