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Case notes

The name of the service user has been changed.

Practitioners: Jane Boulton, team manager and Rebecca Linton, duty social worker.

Field: Hospital social work.

Location: Leicester.

Client: Coral Betts is 89 and lives alone at home with support with shopping and laundry from her daughter.

Case history: Last year Coral fractured her hip but was able to be discharged home from the hospital with some equipment and following physiotherapy was able to continue to live independently. Six months later she fell again while hanging out her washing and badly bruised her hip. She received painkillers from accident and emergency but the discharge team felt there were problems with Coral's mobility and her ability to get on and off chairs, the toilet and so on. Given this it was felt risky to send her home again as she could fall again, particularly as she lives alone. None the less there was confidence that with support and advice she could return to her former independent level of functioning. A programme of reablement with a view to her returning home was preferred. Her abilities could than be re-assessed at the end of the six-week period.

Dilemma: While confident that Coral could return to independent living she, even while in intermediate care, was still falling.

Risk factor: Returning Coral home could result in another fall that may go undetected with worrying consequences.

Outcome: Coral returned home and continues to live successfully independently and to date has not needed the support of social services.

Intermediate care is not yet universally established, despite the leading role given it in health care modernisation and its prominence in the National Service Framework for Older People.

An aim of intermediate care is to make people as independent as they can be with the objective of getting them back into their own homes and keeping them out of long-term care. And in a world where joint working and partnerships are the watchwords, it's easy to see the attractiveness of intermediate care, which by its very nature cannot be the responsibility of one profession, organisation or sector. And a natural home for its promotion is the hospital accident and emergency ward. This is certainly the situation in Leicester where the case of Coral Betts illustrates the potential effectiveness of such services.

Coral, in her late eighties, was unknown to social services. She lived at home alone. About a year ago she fell while hanging her washing out and fractured her hip. Following surgery she was assessed by the hospital's A&E discharge team as being fit to return home with the support of some equipment and physiotherapy.

But six months later she had another serious fall which left her badly bruised. Although not sufficiently ill to require hospital admission, the discharge team did have concerns over her ability to transfer to and from a seating position. Naturally, this increased significantly the risk of Coral falling again.

In past years such a dilemma may well have seen Coral inappropriately returned home or placed in residential care. But she was referred to the hospital social work team and her case was taken up by Rebecca Linton, duty social worker, and the team's manager, Jane Boulton. They, with Coral's agreement, placed her in one of the city's "re-ablement" schemes based in a local authority residential care home.

Coral was assessed to have the potential ability to relearn self-care skills within a short period. "She was happy for this to happen but was also very keen to get back to independent living," says Linton. "Coral gave us good indicators that she could achieve a return home - not least her motivation," adds Boulton.

Importantly, Coral was mentally alert with no indication of confusion. "The fact that Coral had full mental capacity demonstrates how we can look towards problem-solving and agreeing the action to be taken. Quite often you can see the risks presented by a house to falling - loose carpets, loose rugs and so on. It gives us time to work with someone, to set goals with them and reduce and minimise risks, which is all we can do as we can never eliminate risks," says Boulton, whose team keep all cases through any residential or community reablement.

Coral fulfilled expectations and was making excellent progress. "But then she had another fall - and while this might have jeopardised her progress, it became only a setback," says Linton.

While six weeks is the usual maximum stay on the reablement scheme (and the only length of time that is provided free of charge), it was agreed to extend Coral's stay. "While we have a maximum period we are flexible about it - if we think someone still has the potential to progress to independence. However, it's not something we can do indefinitely," says Boulton. Given an extra three weeks, Coral's abilities and confidence increased. "For example, staff were able to show her how to use her walking frame more safely - she tended to lean back which upped the risk of her falling over - so she needed the confidence to stop doing that," says Linton.

Coral was able to return home and without a care package. Her daughter would be able to provide the minimal support it was felt her mother needed.

"We have clear evidence that we've reduced the numbers of people going into residential care by re-abling and supporting people to live independently," says Boulton. "The scheme helps improve users not just physically but also emotionally. And this has increased confidence which can be major stumbling block to independence. Without intermediate care it is possible that Coral might have ended up in residential care."

But it also marks the confidence of staff to take positive risks. As Linton observes: "This is an example of working in a non-ageist way because we have a woman in her late eighties and it's easy to think that this is the time that she's in need of residential care, but we looked upon it more positively."

Arguments for risk 

• Coral has been independent all her life and has never needed any social care input. She has known no other life - and it must be the aim to keep this resourceful, independent woman where she wants to be - at home. 
• Coral was a prime candidate for re-ablement, not least because she was mentally alert and was very motivated about being able to return home. Staff were able to work with her to help her improve her safety awareness and to set clear goals to pave the way back home. 
• Coral was willing to participate and able to agree a clear desired outcome (to move back home). She understood what was expected and what the re-ablement scheme was all about - and this helped to draw up the enthusiasm to succeed.  
• Despite the fall during her re-ablement period, she deserved for the scheme to be flexible and allow her a little more time, to prove that she could overcome that setback.   

Arguments against risk

• Although Coral progressed well during her re-ablement period, even with 24-hour residential specialist supervision she fell again. Her fall history is worrying enough and to return her home without a care package could be inviting a further fall to happen.  
• As she lives alone a further fall might leave her immobilised and undiscovered for a dangerously long period. Only Coral's daughter is known to visit but her visits are occasional rather than regular or routine. 
• National guidance suggests that a period of intermediate care should not exceed six weeks. Coral's fall during her re-ablement period required the scheme to give her a second chance to prove herself. Had she fallen again would her permitted period also be extended again? 
• Only the first six weeks on the scheme is provided free - by extending the period Coral may have been put under financial pressure to get home sooner than might otherwise be safe.

Independent comment 

The case of Coral Betts is a good example of how intermediate care, if applied flexibly, can make a real difference to older people and maintain their independence, writes Martin Green. 

In the past Coral would have found herself with few alternatives to a placement in residential care and on the face of it her case did not look promising for a return home. Yet the outcome was different and it is important to look at what factors were important in enabling Coral to maintain her independence. 

Undoubtedly intermediate care gives Coral another option and allows her the time and the support to prepare for her return home. The crucial factor, however, was the decision to be flexible about how much intermediate care was provided. This case illustrates that while intermediate care cannot be open-ended, it is not helpful to have arbitrarily enforced time-scales. What is much better is for practitioners to be able to take decisions that are appropriate to individual cases. The other factor of critical importance in this case was the positive involvement in the process of Coral herself and the way the re-ablement service gave her practical ways to avoid falls and rebuilt her confidence.  

This case shows that with flexibility, user involvement, and with a positive approach to risk, intermediate care can make a real difference, both improving the quality of people's lives and reducing the need for expensive residential or community services. 

Martin Green is chief executive, Counsel and Care for the Elderly.