PART B: What effective intermediate care looks like

Maintaining consistent flow through intermediate care is critical to achieving the best possible outcomes for people while making the most effective use of available resources, ensuring benefit is maximised across the population. This section sets out what effective intermediate care looks like in practice, to allow systems to assess their current status. Use your findings from Part B to decide which HICs in Part C to prioritise. Each feature described includes:

Descriptions of three maturity levels:

• Not yet established, limited evidence of best practice
• Developing, working towards best practice
• Exemplar, regularly demonstrating best practice
• Data and intelligence that can be used to support self-assessment
• One or two targeted actions for colleagues seeking to take immediate action in this area
• Signposts to the relevant High Impact Change Areas in Part C

How people access intermediate care, from hospital and from the community, is a fundamental factor of effectiveness. Where access is fragmented, with multiple misaligned referral routes, duplicated assessments, and unclear criteria, the system loses time, capacity, and the confidence of referrers and service users alike.

An effective system has co-ordinated access arrangements, with clear referral criteria and processes. Effective intermediate care minimises the number of assessments (with ideally only one assessment to determine needs) and handoffs a person must undergo prior to entry.

[Link to case study]

Data to use

• Total capacity available in intermediate care services, and utilisation rates 
• Utilisation rates of P1, and P2, P3 utilisation rates
• Number of people referred to intermediate care as a percentage of all discharges
• Number of people in hospital with no criteria to reside awaiting home-based intermediate care services
• Number of people who are stepped up to intermediate care from community settings  
• Number of days from referral to commencement of service 

Maturity spectrum

• Foundational: Multiple access points exist with separate criteria. Assessment duplication is common. No single view of available capacity.
• Developing: Referral access points are being rationalised. Shared criteria are agreed in principle. Work is underway to create a single view of capacity.
• Exemplar: One co-ordinated access point operates for both step-up and step-down. Shared triage enables real-time prioritisation and resource allocation decisions. Assessment duplication is eliminated through trusted assessor arrangements.

Targeted action

• Map out all of the access criteria for intermediate care services, and undertake an analysis to identify any significant gaps in the existing offer. Understanding this will either inform an improvement intervention, or create assurance that key population groups do screen in for intermediate care support. Review how easy it is for hospital based staff to make referrals into home based intermediate care services. If the criteria are too restrictive, or referral mechanisms too complicated, this will likely lead to an increase in referrals to bed based intermediate care services.

This action aligns with High Impact Change A - Establish operational grip and create the conditions for continuous improvement

Effective intermediate care requires a clear focus on personalised goals, regular multidisciplinary review and proactive planning for transition from the point of entry into the service.

Goals for people receiving home-based intermediate care should be agreed with the individual and their carer within 24 hours of the service commencing, and communicated to all professionals involved in their support. Regular review through MDT meetings ensures that progress is tracked, goals are adjusted as needed, and people are stepped down from services when goals have been achieved. This supports appropriate length of stay in the service.

[Link to case study]

Data to use

• Proportion of people with goals set within 24 hours of service start
• Goal achievement rates
• People who leave intermediate care with no on-going care requirements 
• People who leave intermediate care with reduced on-going care requirements compared to when they started intermediate care
• Duration of intermediate care compared to expected duration

Maturity spectrum

• Not yet established: Goals are set inconsistently. Reviews are ad hoc. Insufficient involvement of the person and their family members/unpaid carers. Length of stay is not actively managed against expectations.
• Developing: A goal-setting process is in place with regular MDT review. Length of stay is monitored. Transition planning begins at admission.
• Exemplar: Goals are set within 24 hours, co-produced with the individual and their carer, and reviewed at every MDT with involvement of the person and their family members/unpaid carers throughout. MDTs routinely challenge over-prescription of care and promote independence. Transition plans are actively managed from day one. Length of stay consistently matches or improves on expected benchmarks

Targeted actions 

• Define what a ‘goal’ is and ensure that the definition is made available to frontline staff; emphasise that a goal should be measurable and time limited. This definition should be owned by local professional leads and act as baseline for all professionals to work towards.  
• Agree a standard for how regularly goals will be reviewed, so that the person in receipt of services and the team around them has a shared understanding, and who will lead on these reviews (so that these reviews are a core part of service delivery).

These actions align with High Impact Change A - Establish operational grip and create the conditions for continuous improvement

The intermediate care workforce is diverse, spanning registered therapists, unregistered support workers, social workers, nurses, and many others. Staff are employed by a range of organisations. Effective intermediate care systems deploy their workforce in a way that maximises the value of each professional’s skills, matches capacity to demand, and promotes a culture of independence.

In the most effective systems staff may be deployed flexibly across care settings in response to demand and need, based on proactive decision making by the organisations involved.  

A clear competency framework is essential so that teams can be clear on which members have the right skills and capabilities for any given requirement. This supports safety and quality, ensures that people are recognised for their expertise, and enables teams to identify gaps. Both registered and unregistered members of the team bring specific expertise.

Data to use

• Staff utilisation rates 
• Skill mix ratios across pathways
• Agency spend as a proportion of workforce cost
• Staff absence rates 
• Patient and carer experience

Maturity spectrum

• Not yet established: Staff work within traditional team boundaries. Utilisation is not routinely measured. Professional standards are adhered to, but no wider competency framework is in place to support multidisciplinary working. 
• Developing: Utilisation is monitored. Interdisciplinary working is encouraged. A competency framework is being developed.
• Exemplar: Staff are deployed flexibly across pathways based on demand. A competency framework ensures the right skills are matched to need.

Targeted actions 

• Create spaces where multi-disciplinary teams can work together to help foster relationships and understanding. Understanding should lead to conversations about how to collaborate on shared cases 
• Identify opportunities to implement a trusted assessor approach. In some systems, trusted assessment may be embedded and the action is to roll the approach out as far as possible; in other areas trusted assessment will be new. In this situation, it is advisable to choose a specific pathway as a starting point to develop learning.

These actions align with High Impact Change F - Mobilising a flexible intermediate care workforce across locations 

Effective intermediate care puts the person and their unpaid carers/family at the centre. This means explaining the ‘intermediate care deal’ at the outset: what intermediate care is, what it aims to achieve, how long it typically lasts, and how the transition out of intermediate care will happen. Setting people’s expectations helps them to be active partners in providing effective intermediate care services. For example, people and carers should be actively involved in goal-setting and have the opportunity to provide feedback on their experience.

Feedback from users and their unpaid carers should be routinely captured to inform development and service improvement initiatives.

[Link to case study]

Data to use

• Patient and carer feedback and survey outcomes
• Proportion of unpaid carers asked about their ability and willingness to provide care
• Complaints and compliments data

Maturity spectrum

• Not yet established: Information about intermediate care is provided inconsistently. Unpaid carer involvement is minimal. Feedback is not routinely collected.
• Developing: People are given clear information about intermediate care at the start. Unpaid carers are consulted and informed of their statutory rights. Feedback is collected but not systematically acted upon.
• Exemplar: People and unpaid carers are fully involved in goal-setting and transition planning, their statutory rights are explained, as well as non-statutory support available. Feedback is routinely collected, analysed, and used to drive improvement.

Recommended actions 

• Implement a user survey which is sent to everyone who has been through intermediate care, to ask about their experience and the experience of their carers. Initially this survey can be simple, but should include a question which asks people to rate their experience, to create a quantitative evidence base which can be tracked over time. 
• Ensure that there is material available for staff to explain the intermediate care offer, and set expectations appropriately. This material should help staff to explain that intermediate care is time limited support aimed at helping with tasks of daily living and enabling independence.

These actions align with High Impact Changes A and B.

The ultimate measure of effective intermediate care is whether people recover and retain as much function and independence as possible. This means measuring not just throughput and length of stay, but changes in independence levels, successful return home from bed-based care, use of ongoing home care, and avoided admissions and readmissions.

Data to use

• Independence levels before and after intermediate care
• Proportion of people who live independently at home following intermediate care
• Long-term care (care home and home care) uptake following intermediate care
• Acute hospital admission and readmission rates
• Avoided acute hospital admissions (noting the difficulty of measurement)

Maturity spectrum

• Not yet established: Outcome measurement is limited to length of stay and throughput. Independence outcomes are not routinely tracked.
• Developing: Independence outcomes are measured for some pathways. Readmission rates are monitored. There is growing attention to outcomes-based commissioning.
• Exemplar: Comprehensive outcome measurement is embedded, covering independence, readmissions, long-term care uptake, and patient experience. Outcomes data drives commissioning decisions and service improvement.

Targeted action 

• As the basis of an approach to measuring outcomes, start by asking users and carers to explain what matters to them. The independence metrics used by services will be proxy measures for the experience of people using the services. Conversations with users and their carers allow each metric to be clearly linked to lived experience. 
• Commissioners, working with providers, should ensure monitoring and evaluation maintains a broad overview of outputs and outcomes. Consider metrics that measure independence and performance of daily activities (commonly used by AHPs); reduced intensity of care packages; reduced admission to care homes/residential care.

This action aligns with High Impact Changes A and B.

The physical environment in which intermediate care is delivered has a significant impact on outcomes. Home-based settings should be safe and conducive to recovery, with environmental barriers addressed through timely access to home adaptations and equipment. Bed-based settings must be set out to promote independence, not replicate a long-term care culture. For example, it is often the case that intermediate care beds are ‘spot’ purchased with residential care settings. In this context it is extremely challenging to ensure that the person in that bed gets the right rehabilitative input, rather than receiving care similar to permanent residents. A group of defined beds commissioned through a block contract arrangement  are more likely to offer the holistic rehabilitation and reablement input required and lend itself to more effective provision of the wraparound support that can be valuable in promoting recovery and independence.

By right sizing the number of intermediate care beds, systems can shift funds towards home-based intermediate care, allowing more people to achieve better outcomes by being supported in their own homes.

[Link to case study]

Maturity spectrum

• Foundational: The environment does not allow for effective rehabilitation and reablement . Transition planning is reactive.
• Developing: Rehabilitation and reablement principles have been adopted. Expected dates of transition are set.
• Exemplar: All settings operate with a rehabilitation and reablement mindset, with a suitable environment to promote independence. Therapy input is available daily if required. Transition plans are in place from day one.

Targeted actions

• Engage with your Integrated Community Equipment Service provider to ensure that delivery timescales align with the expected commencement times for intermediate care services, and that people resident in care homes can get access to equipment. This prevent delays in starting intermediate care and facilitates discharge. 
• Undertake an audit of Pathway 2 beds to check whether their physical environment is set up to facilitate and enable a rehabilitative approach, and whether the staff around these beds have the right skills and knowledge to work in this way.

These actions align with High Impact Change C - Joint commissioning, shared design principles, and a funding framework.

To get the most value from intermediate care resources — beds, home-based capacity, workforce, and budget — they must be managed collaboratively across the system. This means understanding demand, acuity/complexity of that demand, workforce capacity, and lengths of stay across all pathways, addressing barriers to move-on, managing the total funding for intermediate care, and using resources flexibly to respond to spikes in demand.

Managing intermediate care resources effectively requires system partners to understand not only capacity and flow, but population need, outcomes and value. When commissioners and providers make decisions informed by intelligence on independence outcomes and avoidance of long term care, this enables resources to be deployed where they deliver greatest benefit.

Joint analysis between commissioners and providers can reduce duplication, improve workforce utilisation and support more strategic investment decisions across home based and bed based provision.

Capacity should always be understood in terms of intensity as well as volume: not just how many beds or people are being supported, but the nature and frequency of the support being provided. 

To identify additional or specialist capacity requirements, such as dementia care, population health management data should be used.

Data to use 

• Service demand
• Workforce capacity
• Length of stay by pathway (home-based and bed-based)
• Bed occupancy and throughput
• Costs per episode of care, and costs to deliver particular outcomes, to support evaluation of value for money
• Average weekly cost of a care package
• Intensity: days between first and second care contact
• Availability of community equipment

Maturity spectrum

• Not yet established: Each organisation manages its own capacity. There is no shared view of demand or utilisation. Resources cannot flex.
• Developing: A shared view of capacity and demand is being established. Length of stay is monitored. Joint budget discussions are taking place.
• Exemplar: Resources are managed jointly with a single shared view of capacity, demand, and cost. Capacity flexes in response to demand. Funding planning is long-term and aligned to improvement programmes.
• Targeted action 
  Identify all of the  system-wide spend on the existing intermediate care offer, and quantify the total capacity that this resource is purchasing. This baseline spend data should enable an informed discussion about the value and benefit achieved, and allow for honest conversations about spend which is not achieving clear benefits.

This action aligns with High Impact Changes B and D.

Productive intermediate care requires a coherent set of metrics that spans inputs, activities, outputs, outcomes, and system impacts. The following framework provides example data points.

• Inputs: service projected demand, beds, home-first capacity, rehabilitation and reablement hours, therapy hours, workforce, skills mix, equipment
• Activities: home-first assessments, therapy assessments, MDT triaging, reablement sessions, therapy interventions, personal care plans, carer support plans, reviews
• Outputs: episodes of intermediate care completed, bed-days delivered, starts within 24 hours, length of stay vs expected, avoided delays, bed occupancy, functional improvement
• Outcomes: independence levels, achievement of goals, improved mobility, activities of daily living assessments, reduced care package, avoided residential care
• System impacts: timely access, reduced hospital length of stay, reduced delays, reduced admissions and readmissions, reduced long-term care, reduced GP and community nursing demand, survey outcomes and feedback

Additional recommended metrics include: average weekly cost of a package, intensity and duration of intermediate care, waiting times (referral to assessment and assessment to service), and alignment with ASCOF metrics and the Better Care Fund framework 2026 to 2027.

Relevant ASCOF metrics include:

• The proportion of people who received reablement during the year, who previously were not receiving services, where no further request was made for ongoing support 
• The proportion of people aged 65 and over discharged from hospital into reablement and who remained in the community within 12 weeks of discharge 
• The proportion of people aged 65 and over discharged from hospital, who received reablement services

Maturity spectrum

• Not yet established: Each organisation reviews its own data separately, and uses this data to drive independent decision making. Data is only shared infrequently between partners, and there is little evidence that this impacts on decision making.
• Developing: Data is regularly shared between partners, but there is insufficient trust for partners to collectively review one data set. Data sharing does impact on decision making, but not routinely. 
• Exemplar: All system partners are reviewing one consolidated set of data metrics, including both leading and lagging metrics. Partners trust this data, and is it the evidence base for key decisions. Data creates accountability and responsiveness.

Targeted action 

• Convene a workshop of system partners to agree a long-list of shared metrics which describe the operational effectiveness and impact of intermediate care.
• Agree a process to share this data and agree a rhythm for sharing data. Ensure that there is a space in the system where these agreed metrics can be discussed.
• The behaviour of sharing and discussing one agreed data set will help drive partners towards a shared understanding, and the long-list will be refined.

This action aligns with High Impact Changes B and D.

From understanding maturity to taking action

Part B helps systems understand what effective intermediate care looks like and assess how close they are to this in practice. Part C then builds on this by setting out six High Impact Change areas that respond to the most common gaps and challenges identified through the maturity framework. Systems can use their self‑assessment from Part B to to plan and sequence the actions in Part C in a way that supports whole‑system improvement.