NICE produces quality standard for OTs on reablement

Quality standard outlines best practice for OTs working in reablement

Published on 14th August 2018

Adults who are having bed-based intermediate careto help their recovery should start this within two days of being referred in a bid to help them to regain their independence as soon as possible, NICE has said.

The National Institute for Health and Care Excellence has published a new quality standard on intermediate care including reablement which includes four quality statements for which professionals should adhere to.

NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements.

“Delays in starting bed-based intermediate care can increase the risk of further deterioration in the person's condition and lead to reduced independence. If the move to bed-based intermediate care from hospital or the community takes longer than two days it is likely to be less successful and could lead to admissions to hospital or residential care that could have been avoided,” said the quality standard.

Service providers such as hospitals, community providers, care homes and not-for-profit social enterprises should have processes in place to ensure that adults start bed-based intermediate care within two days of referral from hospital or the community. This may require a coordinated approach to manage demand for intermediate care across local hospital and intermediate care services, for example, through a single point of access for referrals.

Furthermore, health and social care practitioners including nurses and allied health professionals should ensure that adults accepted for bed-based intermediate care start the service within two days of referral from hospital or the community.

The quality standard can be measured by the rate of delayed transfer of care from hospital for adults, the rate of unplanned hospital admissions for chronic ambulatory care sensitive conditions and the proportion of people who were still at home 91 days after discharge from hospital into reablement or rehabilitation services – all monitored by the NHS. The move should also affect the proportion of discharges from bed-based intermediate care to acute hospital or residential care monitored by The NHS Benchmarking Network.

A separate quality statement says that adults being assessed for intermediate care should have a discussion about the support the service will and will not provide.

Healthcare professionals in hospitals or the community who are assessing people for intermediate care should have a discussion, provide information and ensure that the person as well as their family and carers if appropriate understand what intermediate care is and what it can and cannot achieve. This will ensure that people are involved in making decisions about their care and encouraged to engage with the rehabilitation process. It will also enable them to consider any further support they may need in addition to intermediate care, said NICE.

Occupational therapists, social workers nurses and discharge coordinators should ensure that, when they carry out an assessment for intermediate care, they give up-to-date information and have a discussion with the person about the support the service will and will not provide. They should provide information in a suitable format to meet individual needs and record that the discussion took place.

The quality standard goes on to say that adults starting intermediate care discuss and agree personalised goals.

“Involving people in identifying and agreeing their goals for intermediate care will help to ensure that the care is person-centred and focused on their individual strengths and preferences. Setting personalised goals will also encourage the person to be engaged in their care and promote independence. Personalised goals should be reviewed regularly,” said the quality standard.

It adds that health and social care practitioners including occupational therapists, social workers, nurses and care staff need to ensure that they discuss and agree personalised goals with adults starting intermediate care, and their family and carers as appropriate. They should give a copy of the agreed personalised goals, in a suitable format, to the person, their family and carers as appropriate, and staff providing care. Health and social care practitioners ensure that personalised goals are reviewed regularly and that they provide care to support people to achieve their goals.

Finally, adults using intermediate care services should discuss and agree a transition plan for when their support ends. An agreed transition plan for when support from the intermediate care service ends will help to ensure that a person's specific needs are met, transfers to other services are successful and the likelihood of hospital admission is reduced. Transition planning should begin as soon as a person starts using the intermediate care service. The transition plan should be reviewed before discharge to reflect any progress made.

“Health and social care practitioners (such as nurses, social workers and allied health professionals) involve adults starting to use intermediate care services, and their family and carers as appropriate, in developing a transition plan for when their support ends. They ensure that the plan is agreed and documented. They provide a copy of the plan in a suitable format to the person (and their family and carers as appropriate) and review the plan before the person is discharged to reflect any progress made,” said the quality standard.


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