Stage 3: admission to the system

Intermediate care including reablement

1.1.1 Ensure that intermediate care practitioners: develop goals in a collaborative way that optimises independence and wellbeing adopt a person-centred approach, taking into account cultural differences and preferences.
1.1.2 At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and: other agencies people using the service and their families and carers.
1.1.3 Intermediate care practitioners should: work in partnership with the person to find out what they want to achieve and understand what motivates them to focus on the person's own strengths and help them realise their potential to regain independence build the person's knowledge, skills, resilience and confidence learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack support positive risk-taking.
1.1.4 Ensure that the person using intermediate care and their family and carers know who to speak to if they have any questions or concerns about the service, and how to contact them.
1.1.5 Offer the person the information they need to make decisions about their care and support, and to get the most out of the intermediate care service. Offer this information in a range of accessible formats, for example: verbally, in written format, in other accessible formats, translated to other languages, provided by a trained, qualified interpreter.
1.5 Entering Intermediate Care.

1.5.14 Explore the patient's preferences about the level and type of information they want. Based on this, give the patient (and their family members and/or carers if appropriate) clear, consistent, evidence-based, tailored information throughout all stages of their care. This should include, but not be limited to, information on: their condition (or conditions) and any treatment options. Where they will be seen. Who will undertake their care. Expected waiting times for consultations, investigations and treatments.

1.5.2 Ensure staff in contact with older people are aware of the importance of maintaining and improving their independence and mental wellbeing.

1.1 Ensuring care is person centred.
1.1.1 Ensure services support the aspirations, goals and priorities of each person, rather than providing 'one size fits all' services.
1.1.2 Ensure support focuses on what people can or would like to do to maintain their independence, not only on what they cannot do. Recognise: that people have preferences, aspirations and potential throughout their lives and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.

1.2 Medicines-related communication systems when moving from one care setting to another.
1.31 In an acute setting, accurately list all of the person's medicines (including prescribed, over‑the‑counter and complementary medicines) and carry out medicines reconciliation within 24 hours or sooner if clinically necessary, when the person moves from one care setting to another – for example, if they are admitted to hospital.
1.5 Self-management plans.
1.8.2 Organisations should involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.

1.1 Overarching principles of care and support during transition.
1.3.7 As soon as the person is admitted to hospital, identify staff to form the hospital‑based multidisciplinary team that will support them. The composition of the team should reflect the person's needs and circumstances.
1.5.25 Ensure that older people with identified social care needs are offered early supported discharge with a home care and rehabilitation package.
1.5.26 Consider early supported discharge with a home care and rehabilitation package provided by a community‑based multidisciplinary team for adults with identified social care needs.

1.1.6 Home hazard and safety intervention.
1.1.6.1 Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer and appropriate members of the health care team.
1.1.6.2 Home hazard assessment is shown to be effective only in conjunction with follow up and intervention, not in isolation.

1.4 Communicating risks, benefits and consequences.
1.4.1 Discuss risks, benefits and consequences in the context of each person's life and what matters to them. Be aware that risk communication can often be supported by using good-quality patient decision aids or graphical presentations such as pictographs (see recommendations 1.3.1 to 1.3.3).
1.4.2 Personalise information on risks, benefits and consequences as much as possible. Make it clear to people how the information you are providing applies to them personally and how much uncertainty is associated with it. For more on dealing with uncertainty, see the General Medical Council's guidance on decision making and consent.
1.4.3 Organisations should ensure that staff presenting information about risks, benefits and consequences to people have a good understanding of that information and how to apply and explain it clearly (see recommendations 1.1.12 and 1.1.13).
1.4.4 If information on risks, benefits and consequences specific to the person is not available, continue to use the shared decision making principles outlined in this guideline.