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Rationale: Cardiorespiratory insufficiency (CRI) is a term applied to the manifestations of loss of normal cardiorespiratory reserve and portends a bad outcome. CRI occurs commonly in hospitalized patients, but its risk escalation patterns are unexplored., Objectives: To describe the dynamic and personal character of CRI risk evolution observed through continuous vital sign monitoring of individual step-down unit patients., Methods: Using a machine learning model, we estimated risk trends for CRI (defined as exceedance of vital sign stability thresholds) for each of 1,971 admissions (1,880 unique patients) to a 24-bed adult surgical trauma step-down unit at an urban teaching hospital in Pittsburgh, Pennsylvania using continuously recorded vital signs from standard bedside monitors. We compared and contrasted risk trends during initial 4-hour periods after step-down unit admission, and again during the 4 hours immediately before the CRI event, between cases (ever had a CRI) and control subjects (never had a CRI). We further explored heterogeneity of risk escalation patterns during the 4 hours before CRI among cases, comparing personalized to nonpersonalized risk., Measurements and Main Results: Estimated risk was significantly higher for cases (918) than control subjects (1,053; P ≤ 0.001) during the initial 4-hour stable periods. Among cases, the aggregated nonpersonalized risk trend increased 2 hours before the CRI, whereas the personalized risk trend became significantly different from control subjects 90 minutes ahead. We further discovered several unique phenotypes of risk escalation patterns among cases for nonpersonalized (14.6% persistently high risk, 18.6% early onset, 66.8% late onset) and personalized risk (7.7% persistently high risk, 8.9% early onset, 83.4% late onset)., Conclusions: Insights from this proof-of-concept analysis may guide design of dynamic and personalized monitoring systems that predict CRI, taking into account the triage and real-time monitoring utility of vital signs. These monitoring systems may prove useful in the dynamic allocation of technological and clinical personnel resources in acute care hospitals.

Background: An important, but not well characterized, population receiving intermediate care is that of medical patients admitted directly from the emergency department., Objective: To characterize emergency medical patients and their outcomes when admitted to an intermediate care unit with clearly defined admission guidelines., Methods: Demographic data, admitting diagnoses, illness severity, comorbid conditions, lengths of stay, and hospital mortality were characterized for all emergency medical patients admitted directly to an intermediate care unit from July through December 2012., Results: A total of 317 unique patients were admitted (mean age, 54 [SD, 16] years). Most patients were admitted with respiratory (26.5%) or cardiac (17.0%) syndromes. The mean (SD) Acute Physiology and Chronic Health Evaluation score version II, Simplified Acute Physiology Score version II, and Charlson Comorbidity Index were 15.6 (6.5), 20.7 (11.8), and 2.7 (2.3), respectively. Severity of illness and length of stay were significantly different for patients who required intensive care within 24 hours of admission (n = 16) or later (n = 25), patients who continued with inter mediate care for more than 24 hours (n = 247), and patients who were downgraded or discharged in less than 24 hours (n = 29). Overall hospital mortality was 4.4% (14 deaths)., Conclusions: Emergency medical patients with moderate severity of illness and comorbidity can be admitted to an intermediate level of care with relatively infrequent transfer to intensive care and relatively low mortality., (©2016 American Association of Critical-Care Nurses.)

Background Despite the importance placed on the concept of the multidisciplinary team in relation to intermediate care (IC), little is known about community pharmacists' (CPs) involvement. Objective To determine CPs' awareness of and involvement with IC services, perceptions of the transfer of patients' medication information between healthcare settings and views of the development of a CP-IC service. Setting Community pharmacies in Northern Ireland. Methods A postal questionnaire, informed by previous qualitative work was developed and piloted. Main outcome measure CPs' awareness of and involvement with IC. Results The response rate was 35.3 % (190/539). Under half (47.4 %) of CPs 'agreed/strongly agreed' that they understood the term 'intermediate care'. Three quarters of respondents were either not involved or unsure if they were involved with providing services to IC. A small minority (1.2 %) of CPs reported that they received communication regarding medication changes made in hospital or IC settings 'all of the time'. Only 9.5 and 0.5 % of respondents 'strongly agreed' that communication from hospital and IC, respectively, was sufficiently detailed. In total, 155 (81.6 %) CPs indicated that they would like to have greater involvement with IC services. 'Current workload' was ranked as the most important barrier to service development. Conclusion It was revealed that CPs had little awareness of, or involvement with, IC. Communication of information relating to patients' medicines between settings was perceived as insufficient, especially between IC and community pharmacy settings. CPs demonstrated willingness to be involved with IC and services aimed at bridging the communication gap between healthcare settings., Competing Interests: All authors declare that they have no conflict of interest.

Introduction: Care for patients with chronic obstructive pulmonary disease (COPD) can be provided in primary, secondary or tertiary care. Whether and to what extent patients with COPD treated in various healthcare settings differ in disease burden and healthcare utilization remains unknown. Therefore, daily symptoms, functional mobility, mood status, health status and healthcare utilization were compared between COPD patients in various care settings, to explore possibilities for healthcare-optimization., Methods: Current data are part of the Chance study. Demographics, functional mobility (Care Dependency Scale (CDS); Timed-Up-and-Go (TUG) test), mood status (Hospital Anxiety and Depression scale (HADS)), health status (COPD Assessment test (CAT); Clinical COPD questionnaire (CCQ); COPD specific St. George Respiratory questionnaire (SGRQ-C)), received treatments and severity of physical and psychological symptoms were assessed in subjects with and without COPD., Results: 836 subjects (100 primary care patients, 100 secondary care patients, 518 tertiary care patients and 118 non-COPD subjects) were included. The burden of disease significantly increased from primary care to tertiary care. However, in all three healthcare settings a high percentage of patients with an impaired health status was observed (i.e. CAT ≥10 points, 68.0% vs. 91.0% vs. 94.5%, respectively). Furthermore, many patients treated in secondary care remain highly symptomatic despite treatment, while others with low burden of disease would allow for de-intensification of care., Conclusion: This study revealed important shortcomings and challenges for the care of COPD patients in the Netherlands. It emphasizes the need for detailed patient characterization and more individualized treatment, independent of the healthcare setting., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Intermediate care services have developed internationally to expedite discharge from hospital and to provide an alternative to an emergency hospital admission. Inconsistencies in the evidence base and under-developed governance structures led to concerns about the care quality, outcomes and provision of intermediate care in the NHS. The National Audit of Intermediate Care was therefore established by an interdisciplinary group. The second national audit reported in 2013 and included crisis response teams, home-based and bed-based services in approximately a half of the NHS. The main findings were evidence of weak local strategic planning, considerable under-provision, delays in accessing the services and lack of mental health involvement in care. There was a very high level of positive patient experience reported across all types of intermediate care, though reported involvement with care decisions was less satisfactory., (© The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Effectiveness of intensive care treatment is essential to cope with increasing costs. The German national register of intensive care established by the German Interdisciplinary Association for Intensive Care Medicine (DIVI) contains basic data on the structure of intensive care units in Germany. A repeat analysis of data of the DIVI register within 8 years provides information for the development of intensive care units under different economic circumstances., Methods: The recent data on the structure of intensive care units were obtained in 2008 and compared with the primary multicenter study from 2000. The hospitals selected were a representative sample for the whole of Germany. Data on the status of the hospital, staff and technical facilities, foundation of the hospital and the statistics of mechanically ventilated patients were analyzed., Results: The technical facilities and the number of staff have improved from 2000 to 2008. A smaller availability of diagnostic procedures and staff remain in hospitals for basic treatment outside normal working hours. The average utilization of intensive care unit beds was not altered. The existence of intermediate care units did not significantly change the proportion of patients with artificial ventilation or ventilation times. The number of beds in intensive care units was unchanged as was the average number of beds in units and the number of patients treated. A relevant number of beds of intensive care units shifted towards hospitals with private foundation without changes in the overall numbers. The structure of the hospitals was comparable at both time points., Conclusions: The introduction of intermediate care units did not alter ventilation parameters of patients in 2008 compared with 2000. There is no obvious medical reason for the shift of intensive care beds towards private hospitals. The number of staff and patients varied considerably between the intensive care units. The average number of patients treated per bed was not different between the periods or between hospitals with different structures. Overall availability of medical staff and diagnostic procedures increased during the study period. An increase of availability of fully trained medical staff in intensive care medicine is desirable to increase the quality of treatment.

Introduction: intermediate care has been developed to support older people to remain living in their own homes, combining a higher level of support with a rehabilitation focus. Evidence around their effectiveness remains mixed and there is ambiguity around the components., Aims: to establish the impact of intermediate care on institutional free survival in frail older people referred for needs assessment in New Zealand (NZ)., Methods: pre-planned meta-analysis of three randomised controlled trials with follow-up at 3, 6, 12, 18 and 24 months. A total of 567 older people at risk of permanent institutionalisation as well as their primary informal carer (n = 234) were randomised to either intermediate or usual care. Interventions had common key features of care management, though varied in the use of ongoing care provision., Results: the adjusted hazard ratio for the combined primary outcome of death or residential entry was 31% lower with a 95% confidence interval of (9%, 47%) for the intermediate care initiatives compared with usual care., Conclusion: intermediate care utilising a care management approach reduces a frail older person's risk of mortality and permanent institutionalisation.

The National Service Framework for Older People resulted in the widespread introduction of intermediate care (IC) services. However, although these services have shared common aims, there has been considerable diversity in their staffing, organisation and delivery. Concerns have been raised regarding the clinical governance of IC with a paucity of data to evaluate the effectiveness, quality and safety of these services. This paper presents the results of a national pilot audit of IC services focusing particularly on clinical governance issues. The results confirm these concerns and provide support for a larger scale national audit of IC services to monitor and improve care quality.

In France, recent legislation for pediatric critical care organization endorsed the creation of a new level of pediatric care, the intermediate care units. These units treat children who require close monitoring and/or continuous monitoring due to potential failure of 1 or more organs, yet not to the degree of intensity of pediatric critical care. These rules do not provide precise admission and discharge guidelines for the pediatric patients requiring intermediate care. We conducted a questionnaire survey in all pediatric units in 3 French regions: Franche-Comté, Nord-Pas-de-Calais, and Rhône-Alpes. We obtained a response rate of 62.2% from the pediatric units. We estimated the pediatric intermediate care demand, with a unit occupancy rate of 80%, at 1.2 beds per 10 pediatric medical beds, 2.6 beds per 10 surgical beds, and 4 beds per 10 critical care unit beds or hemato-oncology beds. The intermediate care demand was higher in university-affiliated hospitals. One-third of the children referred to these units were less than 1 year old, 1/4 were less than 6 months old. We also described the diseases and potential organ failures of the patients who were referred to these intermediate care units. This study provides an estimate of the demand for pediatric intermediate care as defined in the French legislation and therefore helps implement projects to create such units. More specific criteria are still needed to oversee the implementation of these projects., (Copyright (c) 2010 Elsevier Masson SAS. All rights reserved.)

Intimacy and sexual expression are an integral part of being human and of healthy living. However, this important aspect of well-being is often overlooked or avoided when a person enters a care facility such as a nursing home, group home, or assisted living residence. This article summarizes the new Supporting Sexual Health and Intimacy in Care Facilities Guidelines, which suggest ways of supporting healthy intimacy and sexuality in care facilities.

Objective: To generate a picture of the range, configuration and staffing of community and intermediate care services in the United Kingdom (UK) and to ascertain whether any relationships exist between service configuration and staffing models., Method: A service audit tool was sent to members of the Community Therapist's Network (CTN) and to chief executives of primary care and National Health Service trusts in the UK. Data were collected from the CTN and chief executives of primary care trusts (PCTs) and NHS trusts between late 2005 and early 2006., Results: The overall response rate to the two audits was 37% (n = 243), with 77% of these responses (n = 186) useable. Services varied greatly in terms of their organisation and staffing configurations. Skill mix varied according to the location of service delivery, with home-based services utilising more therapy and support staff than inpatient services. Two clusters of service emerged, based on the number of referrals per year, support staff in the team and the level of care provided by the service., Conclusion: There are no clear patterns to the structure and organisation of community and intermediate care services in relation to their purpose, and it remains unclear how different staffing configurations impact on service costs and patient outcomes. The amount of variation observed indicates that there is likely to be considerable variability in service costs and outcomes for the teams. Further evidence is required to determine the impact of different staffing models, and to identify approaches that optimise both effectiveness and efficiency.

The authors explore the views of practitioners and managers on the implementation of intermediate care for elderly people across England, including their perceptions of the challenges involved in its implementation, and their assessment of the main benefits and weaknesses of provision. Qualitative data were collected in five case study sites (English primary care trusts) via semistructured interviews (n = 61) and focus group discussions (n = 21) during 2003 to 2004. Interviewees included senior managers, intermediate care service managers, clinicians and health and social care staff involved in the delivery of intermediate care. The data were analysed thematically using an approach based on the 'framework' method. Workforce and funding shortages, poor joint working between health and social care agencies and lack of support/involvement on the part of the medical profession were identified as the main challenges to developing intermediate care. The perceived benefits of intermediate care for service-users included flexibility, patient centredness and the promotion of independence. The 'home-like' environment in which services were delivered was contrasted favourably with hospitals. Multidisciplinary teamworking and opportunities for role flexibility were identified as key benefits by staff. Insufficient capacity, problems of access and awareness at the interface between intermediate care and 'mainstream' services combined with poor co-ordination between intermediate care services emerged as the main weaknesses in current provision. Despite reported benefits for service-users and staff, the study indicates that intermediate care does not appear to be achieving its full potential for alleviating pressure within health and social care systems. The strengthening of capacity and workforce, improvements to whole systems working and the promotion of intermediate care among doctors and other referrers were identified as key future priorities.

The objectives of this study were to explore the costs and outcomes associated with different types of intermediate care (IC) services, and also to examine the characteristics of patients receiving such services. Five UK case studies of 'whole systems' of IC were used, with data collected on a sample of consecutive IC episodes between January 2003 and January 2004. Statistical differences in costs and outcomes associated with different IC services and patient groups were explored. Factors associated with variation in IC episode outcomes (EuroQol EQ-5D and Barthel Index) were explored using an econometric framework. Data were available for 2253 episodes of IC. In terms of Department of Health criteria, a large proportion of patients (up to 47% of those for whom data were available) in this study were inappropriately admitted to IC services. As regards service function, compared to supported discharge, admission avoidance services were associated with both lower costs and greater health and functional gains. These gains appear to be driven, in part, by illness severity (more dependent patients tended to gain most benefit). In addition, these gains appear to be larger where the admission was appropriate. Our work suggests a need for the development and application of robust and reliable clinical criteria for admission to IC, and close co-operation between hospital and community service providers over selection of patients and targeting of IC and acute care services to meet defined clinical need.

Background: Individual trials have suggested high levels of general patient satisfaction with intermediate care, but this topic has not been examined in detail., Aims: To identify the key elements of patient satisfaction with intermediate care, and to see whether these can be validly measured using a questionnaire., Method: A questionnaire was developed on the basis of a literature review and piloting with patients and staff on participating schemes (phase I). In phase II, the questionnaire was tested for validity and reliability in a group of patients recently discharged from two "hospital-at-home" intermediate-care schemes. In phase III, a shortened version of the questionnaire was psychometrically tested in five sites taking part in a national evaluation of intermediate care., Results: 96 patients with an average age of 76.5 years took part in phase II. Test-retest reliability was evaluated by repeating the questionnaire 2 weeks later in a subsample of 42 patients. This was "moderate" (kappa 0.4-0.6) for 12 questions, "fair" (kappa 0.2-0.4) for 6 questions and "poor" (kappa 0.1-0.2) for 5 questions. Scores correlated well with the Client Satisfaction Questionnaire (Spearman's r = 0.75, p<0.001). 843 patients (57% of those eligible) from five intermediate-care schemes took part in phase III. Principal components analysis suggested six factors or subscales: general satisfaction, affective response, cognitive response, timing of discharge, coordination after discharge, and access to pain relief, although the last three factors comprised only one question each. The intraclass correlation coefficients in the first three subscales varied from 0.82 to 0.89. Scores for all subscales differed by scheme, suggesting construct validity. Only one question (on general satisfaction) was found to be redundant., Conclusion: The questionnaire, with some minor amendments to improve performance, could be used as a validated tool for audit and research in intermediate care. An amended version and scoring programme is available from us on request.

Background: Intermediate care (IC) services have been widely introduced in England and have the strategic objectives of reducing hospital and long-term care use. There is uncertainty about the clinical outcomes of these services and whether their strategic aims will be realised., Setting: A metropolitan city in northern England., Design: A quasi-experimental study comparing a group of older people before and after the introduction of an IC service. A quota sampling method was used to match the groups., Subjects: Patients presenting as emergency admissions to two elderly care departments with falls, confusion, incontinence or immobility., Intervention: a city-wide service in which a joint care management team (multi-agency, multi-disciplinary) assessed patient need and purchased support and rehabilitation from sector-based IC teams., Outcomes: Nottingham Extended Activities of Daily Living score, Barthel Index, Hospital Anxiety and Depression score, mortality, readmission to hospital, and new institutional care placement at 3, 6 and 12 months post-recruitment., Results: There were 800 and 848 patients, respectively, in the control and intervention groups. Clinical outcomes, hospital and long-term care use were similar between the groups. Uptake of IC was lower than anticipated at 29%. An embedded case-control study comparing the 246 patients who received IC with a matched sample from the control group demonstrated similar clinical outcomes but increased hospital bed days used over 12 months (mean +8 days; 95% CI 3.1-13.0)., Conclusion: This city-wide IC service was associated with similar clinical outcomes but did not achieve its strategic objectives of reducing long-term care and hospital use.

Background: Intermediate care was developed in order to bridge acute, primary and social care, primarily for elderly persons with complex care needs. Such bridging initiatives are intended to reduce hospital stays and improve continuity of care. Although many models assume positive effects, it is often ambiguous what the benefits are and whether they can be transferred to other settings. This is due to the heterogeneity of intermediate care models and the variety of collaborating partners that set up such models. Quantitative evaluation captures only a limited series of generic structure, process and outcome parameters. More detailed information is needed to assess the dynamics of intermediate care delivery, and to find ways to improve the quality of care. Against this background, the functioning of a low intensity early discharge model of intermediate care set up in a residential home for patients released from an Amsterdam university hospital has been evaluated. The aim of this study was to produce knowledge for management to improve quality of care, and to provide more generalisable insights into the accumulated impact of such a model., Methods: A process evaluation was carried out using quantitative and qualitative methods. Registration forms and patient questionnaires were used to quantify the patient population in the model. Statistical analysis encompassed T-tests and chi-squared test to assess significance. Semi-structured interviews were conducted with 21 staff members representing all disciplines working with the model. Interviews were transcribed and analysed using both 'open' and 'framework' approaches., Results: Despite high expectations, there were significant problems. A heterogeneous patient population, a relatively unqualified staff and cultural differences between both collaborating partners impeded implementation and had an impact on the functioning of the model., Conclusion: We concluded that setting up a low intensity early discharge model of intermediate care between a university hospital and a residential home is less straightforward than was originally perceived by management, and that quality of care needs careful monitoring to ensure the change is for the better.

Objective: In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence., Review Methods: The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions., Outcomes: Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost., Results: Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56-2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22-0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20-0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34-0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI-0.5-10.76 days). At longest follow up (3-6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60-1.58). The results were not generally sensitive to study quality., Conclusions: The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.

Background: Intermediate care has become a crucial part of the United Kingdom government's programme for improving services for older people. Older people comprise a substantial part of the user base for these services, and it is increasingly recognized that there is a need for greater user involvement in service development for intermediate care. National initiatives undertaken in intermediate care have sought to widen and deepen the remit of such services, and in this way promote greater independence and improved quality of care for older people. In particular, the government has set out clear plans for reshaping services for older people in the National Health Service Plan and the rationale for greater involvement of older people in service development. This article considers ways in which these national and local objectives may be achieved and considers some of the implications for nursing., Aim: This paper aims to explore the concept of intermediate care and to identify trends and existing evidence of user involvement in care. In this way it charts a possible way forward for the development of a more 'user sensitive' approach., Method: The following databases were searched: Medline, Cochrane Library, the Social Science Citation Index and CINAHL. Key words were 'intermediate care', 'older people', 'formal care', 'primary care', 'social services' and 'geriatrics', used in combination., Findings: The findings from this study indicate that there is considerable scope for increased user involvement in service development for intermediate care. Such challenges may be more effectively met through greater clarity of the concept of intermediate care, and a bridging of user involvement at the practice and policy levels. Nurses are key providers of intermediate care in the community., Conclusions: The involvement of older people in intermediate care service development must be premised on a shared comprehension of the purpose and function of intermediate care. Nurses must be involved in shifting intermediate care from being service-focused to patient-centred. Effective participation eschews the application of global constructs for older people, while supporting greater participation at all levels and robust implementation processes.

Background Intermediate care is a potentially important means of reducing pressures on acute hospitals. However, intermediate care itself is a heterogeneous concept, so to make appropriate comparisons it is important to be able to describe and to group different types of intermediate care services. The aim of this study was to explore the information available from routine data sources to assess its potential for monitoring performance. Methods A retrospective examination of routine community-based data for a newly established intermediate care nursing service over a 12-month period from April 1998 to March 1999. Results The service provided out-of-hours community nursing care for 903 patients in 1071 episodes of care and 6033 recorded contacts. Although information about patient characteristics and episode start-dates were complete, over half the episode end-dates were missing. The data suggested that this was primarily a domiciliary service for people aged 65 years and over, covering six main care programmes: genito-urinary, neoplasm, wound management, elderly care, gastro-intestinal and locomotor care. Most of the referrals were from primary care clinicians. Conclusion Using routine data can provide a reasonably good description of services, enabling appropriate comparisons of similar services. At present, the way we view and count activity can fragment services and increase the stress on clinicians. We need to shift our service-focused approach to a patient-centred one. This can be done now by consistent use of patient identifiers and by encouraging services to plan data linkage. But a gap still remains with regards to outcomes, limiting our ability to measure effectiveness.

Delayed discharges are seen as a litmus test for how the whole health and social care system is working. The problem has been exacerbated by delays in developing intermediate care schemes. There has been less use of the private nursing homes for intermediate care than envisaged a year ago, possibly because of NHS concerns about standards. More support should be given to people with chronic conditions to keep them out of hospital.

In this paper, the intermediate care concept will be developed, and a new definition proposed. The evidence on effectiveness will be summarised, focusing on comprehensive geriatric assessment, admission avoidance, nurse-led units for post-acute care, and supported early discharge arrangements. It is a working premise of the paper that, in principle, intermediate care is not only a "good" but also a necessary "thing". However, with the exception of comprehensive assessment, the evidence for many services that fall under the broad rubric of intermediate care is lacking, inconclusive or negative. The implications of this for both practice and research will be discussed.

The specialism of geriatric medicine has developed considerably in the last half of the twentieth century. In Great Britain it has emerged from its sombre beginnings in Victorian poor law institutions to become one of the largest specialities in medicine encompassing a wide range of disciplines and interests. More recently, there has been a parallel development in "intermediate care" a sweeping phrase that encompasses a wide diversity of practices in a plethora of venues. Although there is considerable attraction in minimising the duration of hospital stay by older people, there is a real risk of intermediate care being used as a euphemism for indeterminate neglect. For older people to benefit from appropriate treatment and care, the lessons learnt by earlier generations of geriatricians, and supported by the international evidence base should not be disregarded. Elderly people need a full multi-disciplinary assessment (comprehensive geriatric assessment) and continued involvement of skilled and trained personnel in their continuing care (geriatric evaluation and management). The recommendations of the British Geriatrics Society on intermediate care are commended and should be adhered to by all planners and providers of intermediate care. There is considerable logic in developing ways in which the two developments can be integrated to build upon the best features of both.

This article highlights findings from three studies into nurse-led inpatient units. The results are not the same in each case, particularly with regard to length of stay, and the authors discuss the possible reasons for this. Further work is needed to develop NLIUs and identify cost savings.

Objectives: This study empirically examined whether dimensions of care cluster in special care units (SCUs) compared with non-SCUs. The relationship between SCU status plus separate measures of the dimensions of care and outcomes for dementia sufferers was then investigated., Methods: Data were drawn from the Intermediate Care Facility Project. The sample (N = 510) included residents with dementia, aged 65 and older, in intermediate care facilities throughout the province of British Columbia. Canada. Longitudinal data included 6 outcomes: cognitive function, behavioral problems of agitation and social skills, physical functioning, and quality of life measured through affect and expressive language skills. Separate multiple linear regression equations were estimated, relating each of these outcomes to 5 dimensions of care: preadmission and admission procedures. staff training and education, nonuse of physical and chemical restraints, flexible care routines and resident-relevant activities, and the environment., Results: The results showed there is virtually no clustering of dimensions along SCU/non-SCU lines. Neither SCU status nor the individual dimensions were highly predictive of outcomes. Residents' affect at t1 emerged as a characteristic that was significantly correlated with other outcomes., Discussion: This Canadian research can be added to the few but growing number of rigorous studies that suggest SCUs are not homogeneous and do not necessarily provide better care than non-SCUs. Moreover, it raises questions about the benefits of "best practice" dimensions of care, regardless of SCU status.

Objective: The study examined the characteristics of residents living in a 450-bed intermediate care facility for persons with severe mental illness in Illinois and sought to determine the factors predicting their utilization of mental health services., Methods: Data on 100 randomly selected residents with a chart diagnosis of schizophrenia were collected using chart review and interviews. Data for 78 residents whose diagnosis of schizophrenia or schizoaffective disorder was confirmed using the Structured Clinical Interview for DSM-IV were included in the analyses., Results: Fifty-three percent of the residents used facility-based specialty mental health services beyond medication management, such as group therapy or a day program. Persons with the least severe psychiatric illnesses and with higher levels of motivation for overall care used the most mental health services. Thirty-five percent of the residents had been discharged to an inpatient psychiatric unit during the previous year. Residents most likely to be discharged to those settings were young men with a history of homelessness who refused facility-based health services., Conclusions: Despite recent policy-driven efforts to improve care in this intermediate care facility for persons with mental illness, the facility continues to have problems addressing the mental health needs of the residents.

Increasing demands, limited resources and an aging population are driving the development of alternatives to the full acute hospital bed. This review considers some opportunities and pitfalls, and proposes some principles for practice.

Accreditation promotes continuous quality improvement of systems that affects the quality of patient care delivered, attains desirable clinical and financial outcomes and strategically positions the subacute care provider in the rapidly changing health care delivery system. Thus, as consumers and purchasers of health care plans continue to demand quality care with the best possible outcomes at significant cost savings, accreditation may become the panacea of the future.

Rapidly changing expectations and environments have put health care facilities under increasing pressure. Using traditional strategic planning to deal with these challenges has often produced disappointing results. This article outlines a different approach, based on Robert Fritz's model of the creative process, and discusses its application in Kiwanis Lodge in West Vancouver, an intermediate care facility.

Objective: To determine the impact of OBRA 87 on antipsychotic prescribing in a 485-bed nursing home., Design: Twelve-month retrospective cohort review of medical charts, medication administration records, and computerized pharmacy records., Measurements: The percent of residents by diagnostic group and antipsychotic use., Main Results: An attempt was made to stop or lower the dose of antipsychotic in 75% of the 107 residents studied. Antipsychotics were stopped in 45% of residents with a dementia-only diagnosis and 25% of residents with a psychiatric diagnosis (P < 0.05). Residents with documented symptoms appropriate for the use of antipsychotic, per OBRA 87, were significantly less likely to have their antipsychotic stopped. Twenty percent of residents whose antipsychotic was either stopped or its dose lowered had the agent restarted or its dose increased., Conclusion: OBRA 87 had a significant impact on antipsychotic use in this facility.

The impact of a focused drug regimen review process based on clear objectives and of interdisciplinary team cooperation is described. By shifting from a pharmacy departmental focus, which was primarily on drug distribution activities, to a broader agenda that promotes pharmacists as clinicians, inroads were made in reducing medication doses per resident, decreasing nursing time spent in medication administration, and decreasing pharmacy expenses in this residential facility for the developmentally disabled.

Nursing home ombudsmen represent a community presence in long-term care facilities. This study examines ombudsmen in the context of Litwak's theory of complementary roles in order to assess the theory's association with quality of care. A multivariate analysis of a random sample of 210 Missouri nursing homes revealed that the presence of an ombudsman in intermediate care facilities is significantly related to both process and outcome measures of quality of nursing care. The implication is that conceptualizations of complementary roles should include the quality assurance functions illustrated by ombudsmen.

Objective: To assess physicians' detection of pain among geriatric nursing home residents and to determine if there are factors that may interfere with their ability to do this., Design: Chart review and patient interview., Setting: Geriatric nursing home., Participants: One hundred nursing home residents age 65 or older. Seventy-six were communicative., Measurements: Demographic information, diagnoses, and medication use were compared for several groups of residents to determine their effects on the detection of pain., Results: Sixty-six percent of the communicative residents were identified as having chronic pain. Treating physicians did not detect this problem in 34% of these residents. Those whose pain was not so identified were more likely to have a neurologic disorder other than dementia. When non-communicative residents were compared with those who were communicative, the physicians were found to have identified pain less frequently in the former cohort., Conclusions: Chronic pain is a common problem among geriatric nursing home residents and is frequently undetected. Identification of this problem among communicative residents may be markedly improved by direct questioning about this problem at frequent intervals. New methods of assessing pain need to be created to assist in its detection among the non-communicative population.

Regulations and voluntary standards within the context of organizational design and mission as well as leadership in management for quality were discussed. Rules and regulations are closely associated with the structure and mission of the organization. Altering them may require fundamental redesign of organizational structure and purpose. Likewise, alterations in organizational design can change the need for rules and regulations. In addition, standards do not automatically yield quality. Rather, they define expected levels of performance from individuals, programs, and the organization. The senior management of organizations is responsible for exercising the leadership in managing for quality.