For bed based intermediate care
For bed based intermediate care, expected operational standards are set out in the Delivery Model for Community Beds. These requirements apply to all NHS providers delivering community bedded care.
The problem
In many systems, intermediate care delivered by health and social care services are still organised and delivered separately, creating fragmented care with gaps, overlaps, and confusion. Operational models for home-based intermediate care show considerable variation, with some areas running parallel social care and community health approaches, while others have merged into a single offer.
Integration can take multiple forms: pathway-based integration, aligned service approaches, or deeper functional integration within new structures. Rather than attempting to impose a uniform model across the country, the aim is to capitalise on the opportunities that collaborative working provides.
Voices from stakeholders
“We have a Head of Intermediate care post, jointly funded by health and the local authority, as a single point of escalation and oversight”.
“We joined up reablement, home first, crisis support, and admission avoidance. Whether it’s step up or step down, people just come into short-term support”.
Actions
D1. Map and streamline existing teams into a coherent, integrated offer with strengthened care co-ordination
| Step | Action |
| Step 1 | Consider integrated service models appropriate to local context and existing teams available: pathway-based, aligned services, or deeper functional integration of existing teams. |
| Step 2 | Invest in shared training, shared IT systems, information governance infrastructure and integrated management structures to break down silos. |
| Step 3 | Agree co-ordination arrangements appropriate to local context — whether through care transfer hubs, single points of access, or other integrated approaches at place level. |
| Step 4 | Establish clear, standardised pathways for both step-up and step-down, with defined roles and responsibilities across teams. |
When home-based intermediate care services are commissioned with providers who are assigned a specific geographic area to operate this leads to improved outcomes for service users, as well as increased efficiency and utilisation of resources.
Productivity impact
More integrated working delivers both efficiency gains (through reduced duplication and handoffs) and outcomes gains (through more co-ordinated, person-centred care).
[Link to case study]