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Case notes

Practitioners: Paddy Goslyn, project manager, Caroline Barr, occupational therapist, and Margaret Snell, nurse co-ordinator, assessment and intervention service, Reading Primary Care Trust.

Field: Older people's services.

Location: Reading, Berkshire.

Client: Victoria Featherstone, 76, has lived alone for many years and has been using a wheelchair for five years.

Case history: Apart from using some day care services, Victoria has refused input from social services, partly because in the past she was deemed ineligible for services. Last year she was admitted into hospital with a fractured knee. After surgery she was moved from an acute hospital to an intermediate care in-patient unit, which has a hospital-like environment. While there, Victoria's rehabilitation was slow. She lost all confidence. She would not get out of bed or walk without someone to support her; she had been living from her wheelchair for so long her anxiety about walking again was overwhelming.

Dilemma: If Victoria is to return home safely this needs to be with a degree of social care support - something that she refuses to entertain.

Risk factor: With Victoria's confidence shattered and her self-imposed dependence on her wheelchair, even a simple failure - such as falling - at improving her independence could backfire.

Outcome: After a lengthy but successful rehabilitation, Victoria is now back home living independently.

It is remarkable to think that, just a few years ago, an older person admitted for surgery might be faced with the option of leaving hospital to either go home or go into a home.

The widespread introduction of intermediate care, where people are given time to regain their independence, has reduced the number of people being sent home too early or placed into residential or nursing care unnecessarily.

However, with the added pressures of freeing up hospital beds, intermediate care tends to have a rather prescriptive time limit, with usually six weeks being given to prove yourself fit to return home. But older people, in particular, might simply need more time.

Based at Tanfield, a residential unit in Reading, Berkshire, the assessment and intermediate care rehabilitation unit was set up in recognition that not all rehabilitation of older people should or could be fast-tracked. One such person proved to be Victoria Featherstone, 76, who was admitted to hospital for an operation on her knee, which had kept her immobile and in a wheelchair for more than five years.

Initially placed in an intermediate care in-patient unit, her slow progress meant she was referred on to Tanfield, a 31-bed unit. Twelve beds are for intermediate care rehabilitation, eight for elderly mentally ill (in a separate unit), eight remain residential care clients, and three for assessment and intervention.

"We have a range of intermediate care services from in-patient units to Tanfield to home care," says intermediate care services manager Sandra Pickwick. "Staff at the in-patient unit could say that Victoria would be better suited at Tanfield. We realised that, although the rehab beds were usually time-limited to six weeks, some people can get better in their own time. We aren't prescriptive but we look to offer about six months."

Nurse co-ordinator Margaret Snell says: "Victoria wouldn't attempt to do anything when she came. She was walking but she wanted a carer with her the entire time."

Occupational therapist Caroline Barr says: "The pain had gone after the operation so she was able to walk but, because she had been used to living from a wheelchair, her anxiety levels were hindering her rehab."

Staff also realised that hospital environments were not conducive to Victoria's rehabilitation. Project manager Paddy Goslyn says: "One of our objectives is to provide a non-medical and safe environment for assessment and intervention for patients."

And Tanfield, with its self-contained units, allows people to live in a domestic setting. "The units are like bedsitters with a toilet, wash basin and kitchenette," says Snell. "They've got everything they need - and what is also nice is that many of these people have something similar at home. People in sheltered housing often have small flats. It's like going from home to home. We can get them doing daily living activities because those are the things they need to succeed at to prevent them ending up back in the system."

Barr adds: "Victoria's move from a hospital-type environment to one of our self-contained flats gave her confidence. It wasn't so far to walk to the toilet, for example."

Part of Snell's task of improving independence is to teach people to self-medicate again. "When patients are in hospital they have that skill taken away from them," she says.

The signs were promising. Barr says: "Victoria started feeling confident about going home. We did a home visit with her to make sure that she could manage equipment and get to the toilet by herself. She had been used to being in the kitchen in a wheelchair so it was just about re-orienting herself."

However, it was clear that social services support would be needed to help ease the anxiety about being at home. Victoria agreed. "And that was a big step forward because in the past she had not accepted services from us at all," says Gosling. "But having gone through the rehab system she agreed to accepting help."

Goslyn appreciates that services are targeted around an individual's needs when they come into rehab. "Years ago you used to hit the hospital discharge wall. You come out of hospital and the choice was home or residential or nursing care. But now you have the rehab and community care wall with a multitude of choices - a better service for the patient all round," he says. Victoria Featherstone, for one, is unlikely to disagree.

Arguments for risk

• It is likely that, even with more conventional intermediate care services being available, Victoria would have ended up in residential care. Her confidence was so shattered that she would have returned to the comfort zone of her wheelchair. But with the choice available through rehabilitation, time could be spared to build up relationships and confidence in her own time. 
• The multi-disciplinary team based at or linked to Tanfield (including unit manager, nurse coordinator, GP, occupational therapist, physiotherapist, intermediate care social worker, community psychiatric nurse and care staff) had the breadth and wealth of skills on site or on call needed to support Victoria's progression. 
• Victoria had refused all social care help in the past. However, because of the service at Tanfield, she could build up relationships of trust with both health and social care staff - and when community support was offered to help her return home she agreed.   

Arguments against risk 

• As the physical and mental health of older people begin to deteriorate, confidence becomes more fragile. Victoria had lost the confidence to walk and had become dependent (both physically and mentally) on her wheelchair. That loss of confidence in walking extended to all aspects of her life. As attempts were made to encourage her to walk it would possibly need only one fall or one failure to convince her that she would never walk again and compound a dependence that could only be met with 24-hour care. 
• The length of time clearly needed to work with Victoria to secure some degree of independence would in itself cast doubt over the suitability of a move back home. Being away so long - never mind the financial worry that entails - would make returning home seem like another move to somewhere different. And the moving of older people to different "homes" is potentially detrimental and at worst life-threatening.   

Independent comment

Who does this woman think she is, refusing input from social services? In the not-so-distant past such a show of arrogant ingratitude would have smartly terminated the contact, writes Jef Smith. But not looking for an acceptable alternative would probably have led to imposition of a residential care option. Victoria's story shows there has been substantial progress in offering a real choice of services however eccentric an older person's prejudices may seem. 

After all, to feel unhappy about having strangers come into your home to provide care when you are still vulnerable is reasonable. Victoria had confidence in the NHS and its staff and she preferred her rehabilitation to take place under health auspices. Tanfield's self-contained domestic units with their accessible kitchenettes and personal toilet facilities are a far cry from the average hospital. But with such a high proportion of patients elderly and many needing rehabilitation, shouldn't all acute hospitals soon be looking like Tanfield? 

Allowing only six weeks for a patient to become fully active after surgery was too rigid. It was intended to pressurise professionals who presumed that all care was long term and no older person ever got better. But that battle has been won.  

The risk of a collapse of Victoria's confidence was well guarded against. One quibble: Tanfield should stop calling its accommodation "beds", an inappropriate term for people learning to stand on their own legs; "places", please. 

Jef Smith is a writer, trainer and consultant in care for older people.