Intermediate Care and Community Geriatrics
One of my sub-specialities is in community medicine and this was a section I prepared for a medical textbook which is not going to be published… so I can share it here!
Intermediate care is defined as a range of integrated services that fill the gap between the acute hospital and primary care. These can promote recovery from acute illness, prevent unnecessary acute hospital admissions, prevent admission to a care facility prematurely, facilitate an early supported discharge from the acute hospital and help to maintain independent living.
The key is to assess each patient individually and tailor support over a defined time-period in collaboration with the multidisciplinary team. There are four main models in use within the UK: bed-based intermediate care, home-based intermediate care, crisis response and reablement. Reablement is offered to those who are living independently but have lost their confidence or skills, usually following an acute illness.
THE ROLE OF THE GERIATRICIAN IN THE COMMUNITY
Not all patients receiving intermediate care will require input from a geriatrician, however, they may offer support through “virtual ward round” or undertaking a home visit.
Geriatricians may be asked to review those patients who have reached a “crisis” point. This may be due to an acute illness or it may be that there has been a break down in social support. For some patients, it is absolutely the correct thing to do to admit to an acute hospital. Whilst for others, through multi-disciplinary working and completion of a Comprehensive Geriatric Assessment the correct thing to do is to keep them within the community.
Geriatricians tend to cover “step-up” and “step-down” beds within in a community hospital, working within the multidisciplinary team to try to promote recovery and independent living.
Geriatricians also work closely with primary care, often seeing patients that have complex co-morbidity and frailty either at home or in a residential setting. Through case-finding it may be possible to prevent a “crisis” but also allows for the implementation of discussions surrounding Advance Care Planning.
COMPREHENSIVE GERIATRIC ASSESSMENT
This is an integrated multi-disciplinary, multi-domain assessment of the medical health, mental health, functional capacity and social set up of an individual. It allows the development of problem lists and from this goals and interventions to tackle these can be sought. It is patient focused and will vary from one individual to another. It is not a one
-off assessment, but a process that can be continually evaluated and amended. Within the community, a case manager will often oversee a care plan that has been drawn up from the CGA.
It is useful during an acute illness with decline in function, when undergoing a transfer of care e.g. for rehabilitation, pre-operatively or for those experiencing geriatric syndromes such as falls. It has been shown to improve outcomes in older patients when applied in a consistent manner using validated tools
ADVANCE CARE PLANNING
This is a term describing discussions between family, carers, health care professionals about their future wishes and priorities of care at the end of life. The focus is on what is important to an individual, what they would want and not want to happen e.g. admission to hospital, and who would be their advocate. It is important to note that an ACP is not a legally binding document but helps to inform care givers what an individual would want, should they not be able to speak for themselves.