The Intermediate Care ‘Step Away’ model

A holistic community support approach with testing of frailty score-based interventions


Sharing learning

In 2021, the Brighton Homeless and Inclusion Health Specialist Service with Sussex Community NHS Foundation Trust secured funding from the Department for Levelling Up, Housing and Communities and Brighton & Hove City Council to deliver an Intermediate Care ‘Step Away’ programme. This required a multi-agency approach between medical experts, nursing and other allied health professionals to provide support for homeless and insecurely housed patients in the community after being discharged from hospital.

Fulfilling Lives South East (FLSE) is committed to improving systems and services locally for people experiencing multiple and complex needs and a partnership has been formed between our teams to share learning with the wider system by establishing a Steering Group for the agencies involved in the ‘Step Away’ service.

Our data collection gives an overview of the patients supported by the ‘Step Away’ service:

  • Between May 2021 and January 2022 a total of new 33 patients have been referred.
  • Most patients were aged 40 to 59.
  • Two thirds were male.
  • 55% of patients had further support needs such as drug and alcohol dependency and mental health issues.
  • Most patients lived in hostels, temporary accommodation, emergency accommodation or sleeping rough.

FRAILTY

One element in particular has stood out in the Step Away service data:.  patients were a lot more frail than the average population in the same age category. The Step Away team and FLSE started to focus our attention to this element of the service and build up a better picture of the patients.

The Edmonton Frail Scale, has been used as the chosen assessment tool for frailty and anyone trained is able to use it not just healthcare professionals. The Edmonton Frail Scale covers cognition, general health status, functional independent, social support, medical use, nutrition, mood, continence and functional performance.

Our findings were worrying – more than half the patients had moderate and severe frailty.

OUR LEARNING

We have shared our learning from the ‘Step Away’ service at the Pathways from Homelessness Conference in March 2022 to a wide audience.

We know that a small group of complex patients have more intensive support and care needs. The frailty score is a key tool to identify people’s level of support and care needs, incl. poly-pharmacy issues and raising concerns around personal care needs and mobility.

It is a tool to communicate well the health and care needs of another person to different parts of the wider support system, such as housing and adult social care teams, without too much clinical language. This makes it more accessible across professional teams sitting in different parts of the system. It also helps younger patients to better understand their own frailty and the implications this may have on their lives.

WHAT WE WOULD LIKE TO SEE NEXT

  1. Frailty scores need to be integrated into housing options assessment tools to help allocate care and support 
  2. Investment in a one-stop-shop clinic to respond to the moderate and severe frailty scores (especially for patients with multiple and complex needs) – this will improve accessibility to services and lead to better diagnosis and clinical investigations 
  3. Long term substance use to be seen as a chronic health condition – this impacts on frailty of patients. We support the recent Dame Carol Black review where she called on the government and society to recognise addiction as a chronic health condition

The full presentation the team delivered at the Pathways from Homeless conference 2022 can be found here.


Authors:

Michaela Rossman and Rebecca Rieley

For further information about Fulfilling Lives work in this area, please contact:

System Change Officer

michaela.rossmann@sefulfillinglives.org.uk

Rebecca Rieley, Systems Change Lead:

rebecca.rieley@sefulfillinglives.org.uk  

For more information sign up to our newsletter:

https://bht.us6.list-manage.com/subscribe?u=b43e61c311da27ad5194daffe&id=148d2193de