ࡱ> K|bc( / 00DArialNew bb|Cbhb0bB 0xbDBook Antiquab|Cbhb0bB 0xb DWingdingsuab|Cbhb0bB 0xb0DTimes New Romanbhb0bB 0xb@ .  @n?" dd@  @@`` 80X(   !( 0AA@@wʚ;ʚ;g4VdVdbB 0bppp@ <4ddddĶbpC 0bTCb <4!d!dĶbhG 0bb80___PPT10 ppIntermediate care can not workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL} Outline)Linguistic, philosophical considerations  Intermediate Coming or occurring between two things, places etc.  Occurring or coming between two points in time or events OED 2005(|6ECare< Burdened state of mind arising from fear  Serious or grave mental attention  Used of destitute ... Who is judged fit for official guardianship OED 2005Intermediate care A range of services at the interface between secondary care and primary care  .. Intended to reduce avoidable hospital admission .. Improve transition from hospital to home. From Steiner & Walsh RCT (BMJ 9/3/05)Intermediate care definitionsMay focus on: Stage in a pathway Degree of expertise Quantity of resources Location of service Intention of service There is no useful definitionf    Can Intermediate Care work?In the absence of any agreement whatsoever about the meaning of IC, and With different people and organisations including and excluding different things It is not possible to conclude that it works Because some people will say that something that is not IC is in fact responsible:R4     Aims of health care system?&To maximise social participation of patient maximise role function maximise social status To maximise well-being of patient somatic and emotional achieving satisfaction (adaptation) To minimise stress on & distress of relatives somatic and emotional-.":.-."..   Major objectives of health careREnsure that pathology is identified and any specific treatments given Then Maximise or optimise the patient s Behavioural repertoire (their activities) Ability to adapt to changes in life circumstances Environment (physical and social context) Minimise the patient s distress Minimise carer burdenfF#6F#6  Hospital careFocused (increasingly) on Pathology Diagnosis (assessment, investigation) Treatment (surgery, drugs) Monitoring (usually out-patient) Physiological (bodily) support ITU etc Processes are largely Short-term, quick Independent of context b) b ) Hospital care and activitiesNecessary support is given Toileting, feeding, washing, dressing Context (environment) is hostile Physically, socially, personally Minimal effort to help recovery Therefore left with a patient who cannot go home`&!!R&!!RWhat process is needed?. A problem-solving process Focused on activities Assessment (diagnosis, formulation) identification and analysis of problems Goal setting Interventions that are characteristically multi-focal, and spread over-time Reassessment (monitoring)0$(7"0   (7"  Structure neededA multi-disciplinary group of people who: work towards common goals for each patient involve and educate the patient and family have relevant expertise and knowledge can resolve most common problems In other words, a specialist teamz*"*   b` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@,?" dd@  " @ ` n?" dd@   @@``PR    @ ` ` p>> f(    6|  `}  T Click to edit Master title style! !  0  `  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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JSocial Context 0 ^B T 6DoF  9 XB T 0Do F9 ^B T 6DoGG@XB T@ 0DoCtlXB T 0Do&Fr2 T s *C"? q  T 0   >Choice(2XB T 0Do}j}r T s *C"?  s  T <Bo"`  cWithin person invisible0(2   T <lBo 9 dWithin society invisible0(2   T <QocK  m!External Independently verifiable0 (2  T <h]o"`Ia  cWithin person invisible0(2  XB T 0D3Ԕ9 q9 RB T s *D3>9 RB T s *D3>RB T s *D3>qRB  T s *D3>RB !T s *D3>qq9 RB "T s *DfԔ9 9 RB #T s *DfԔ9 RB $T@ s *DfԔqRB %T s *DfԔ9 qqRB &T s *DfԔ9 q9 RB 'T s *D3>9 q9 H T 0޽h ? ̙33y___PPT10Y+D=' b= @B + b PX6(  Xx X c $|z   ~ X s * `  H X 0޽h ? ̙33$ b D$(  Dr D S  ќ `}   r D S $  `  H D 0޽h ? 3380___PPT10.E`"rX#*&7-}/13()6OHZps/*ln>ux1e[0"( / 00DArialNew bb|Cbhb0bB 0xbDBook Antiquab|Cbhb0bB 0xb DWingdingsuab|Cbh     On-screen Show28 Polstead Roadn# $Arial Book Antiqua WingdingsTimes New RomanDefault DesignIntermediate care can not workOutline IntermediateCareIntermediate careIntermediate care definitionsDoes intermediate care Root EntrydO)6f~Current UserFJSummaryInformation( PowerPoint Document(@  @@`` 0%(   !(  !"# 0AApf@wʚ;ʚ;g4VdVdbB 0bppp@ <4ddddĶbpC 0b/b <4!d!dĶbhG 0bb80___PPT10 pp*Intermediate care can not workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL} OutlineLinguistic, philosophical considerations Consideration of clinical problem faced Discussion of the solution needed Demonstration that the introduction of intermediate care was irrational and causes confusion rehabilitation, in contrast, is rational, works, and fulfils the clinical need:tp Intermediate Coming or occurring between two things, places etc.  Occurring or coming between two points in time or events OED 2005(|6ECare< Burdened state of mind arising from fear  Serious or grave mental attention  Used of destitute ... Who is judged fit for official guardianship OED 2005Intermediate care A range of services at the interface between secondary care and primary care  .. Intended to reduce avoidable hospital admission .. Improve transition from hospital to home. From Steiner & Walsh RCT (BMJ 9/3/05)Intermediate care definitionsMay focus on: Stage in a pathway Degree of expertise Quantity of resources Location of service Intention of service There is no useful definitionf    Can Intermediate Care work?In the absence of any agreement whatsoever about the meaning of IC, and With different people and organisations including and excluding different things It is not possible to conclude that it works Because some people will say that something that is not IC is in fact responsible:R4     Aims of health care system?&To maximise social participation of patient maximise role function maximise social status To maximise well-being of patient somatic and emotional achieving satisfaction (adaptation) To minimise stress on & distress of relatives somatic and emotional-.":.-."..   Major objectives of health careREnsure that pathology is identified and any specific treatments given Then Maximise or optimise the patient s Behavioural repertoire (their activities) Ability to adapt to changes in life circumstances Environment (physical and social context) Minimise the patient s distress Minimise carer burdenfF#6F#6  Hospital careFocused (increasingly) on Pathology Diagnosis (assessment, investigation) Treatment (surgery, drugs) Monitoring (usually out-patient) Physiological (bodily) support ITU etc Processes are largely Short-term, quick Independent of context b) b ) Hospital care and activitiesNecessary support is given Toileting, feeding, washing, dressing Context (environment) is hostile Physically, socially, personally Minimal effort to help recovery Therefore left with a patient who cannot go home`&!!R&!!RWhat process is needed?. A problem-solving process Focused on activities Assessment (diagnosis, formulation) identification and analysis of problems Goal setting Interventions that are characteristically multi-focal, and spread over-time Reassessment (monitoring)0$(7"0   (7"  Structure neededA multi-disciplinary group of people who: work towards common goals for each patient involve and educate the patient and family have relevant expertise and knowledge can resolve most common problems In other words, a specialist teamz*"* Characteristics of servicePatient s disease is not the focus of action Importance of patient s social roles Emphasis on minimising stress/distress Consideration/involvement of family Multiple interventions & coordination Expertise and specialisation Presence of longer-term goals6';NotepNo mention of Location Management organisation Specific professions Timing/phase of illness Amount of resources 6bbNote - 2xStructures are inclusive Processes are generic Outcomes are broad Name for this service is R E H A B I L I T A T I O NX]   &AndRehabilitation does workEvidence Spinal cord injury success Systematic reviews and meta-analyses Stroke, multiple sclerosis, head injury etc Randomised, controlled studies Large parallel groups High level aspects Single case, case series More detailed aspects Controlled clinical trials (CCTs)@,"@, "EvidenceThe evidence supports the process, and says less about content Features: Expertise & specialism Problem-solving, educational approach Co-ordination Multi-professional Involvement of patient & family8I~(~U hRehabilitationIs intermediate illness management Between Pathology and person Hospital and home (and work) Beginning and end Health and other agencies J+^ ^ Rehabilitation Clear definition of structure, process and outcome Not defined or characterised by: Location Staff Organisation Time Age/diseaseBT- T- vIntermediate care No agreed definitions Variably charact-erised by: Location Staffing Organisation Time Age/diseaseB40 4045Two other differencesIntermediate care is politically defined and driven has no underlying logic or model Rehabilitation is clinically defined and driven is logically consistent and grounded in a coherent, agreed modelXCbCbConclusion - 1Intermediate care should be abandoned A political chimera, varying with circumstances Not coherent, and causes confusion Does not uniquely satisfy any clinical need Unsupported by the limited evidence available (1 trial) 0&   !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIe}dMNOPQRSTUVWXYZ[\]^_`afghijklmnopqrstuvwxyz{LJDocumentSummaryInformation87b0bB 0xb0DTimes New Romanbhb0bB 0xb@ .  @n?" dd@  @@`` PHd(   !( 0AA@@wʚ;ʚ;g4VdVdbB 0bppp@ <4ddddĶbpC 0bTCb <4!d!dĶbhG 0bb80___PPT10 ppIntermediate care can not workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL} Outline)Linguistic, philosophical considerations  Intermediate Coming or occurring between two things, places etc.  Occurring or coming between two points in time or events OED 2005(|6ECare< Burdened state of mind arising from fear  Serious or grave mental attention  Used of destitute ... Who is judged fit for official guardianship OED 2005Intermediate care A range of services at the interface between secondary care and primary care  .. Intended to reduce avoidable hospital admission .. Improve transition from hospital to home. From Steiner & Walsh RCT (BMJ 9/3/05)Intermediate care definitionsMay focus on: Stage in a pathway Degree of expertise Quantity of resources Location of service Intention of service There is no useful definitionf    Can Intermediate Care work?In the absence of any agreement whatsoever about the meaning of IC, and With different people and organisations including and excluding different things It is not possible to conclude that it works Because some people will say that something that is not IC is in fact responsible:R4     Aims of health care system?&To maximise social participation of patient maximise role function maximise social status To maximise well-being of patient somatic and emotional achieving satisfaction (adaptation) To minimise stress on & distress of relatives somatic and emotional-.":.-."..   Major objectives of health careREnsure that pathology is identified and any specific treatments given Then Maximise or optimise the patient s Behavioural repertoire (their activities) Ability to adapt to changes in life circumstances Environment (physical and social context) Minimise the patient s distress Minimise carer burdenfF#6F#6  Hospital careFocused (increasingly) on Pathology Diagnosis (assessment, investigation) Treatment (surgery, drugs) Monitoring (usually out-patient) Physiological (bodily) support ITU etc Processes are largely Short-term, quick Independent of context b) b ) Hospital care and activitiesNecessary support is given Toileting, feeding, washing, dressing Context (environment) is hostile Physically, socially, personally Minimal effort to help recovery Therefore left with a patient who cannot go home`&!!R&!!RWhat process is needed?. A problem-solving process Focused on activities Assessment (diagnosis, formulation) identification and analysis of problems Goal setting Interventions that are characteristically multi-focal, and spread over-time Reassessment (monitoring)0$(7"0   (7"  Structure neededA multi-disciplinary group of people who: work towards common goals for each patient involve and educate the patient and family have relevant expertise and knowledge can resolve most common problems In other words, a specialist teamz*"* Characteristics of servicePatient s disease is not the focus of action Importance of patient s social roles Emphasis on minimising stress/distress Consideration/involvement of family Multiple interventions & coordination Expertise and specialisation Presence of longer-term goals6';NotepNo mention of Location Management organisation Specific professions Timing/phase of illness Amount of resources 6bbNote - 2xStructures are inclusive Processes are generic Outcomes are broad Name for this service is R E H A B I L I T A T I O NX]   &AndRehabilitation does work b PX6(  Xx X c $|z   ~ X s * `  H X 0޽h ? ̙330 b `\0(  \x \ c $ `   x \ c $8 `  H \ 0޽h ? 3380___PPT10..X$ b D$(  Dr D S  ќ `}   r D S $  `  H D 0޽h ? 3380___PPT10.E`"$ b p`$(  `r ` S ֤ `}   r ` S P `  H ` 0޽h ? 3380___PPT10.EbP\$ b d$(  dr d S Ӥ `}   r d S X `  H d 0޽h ? 3380___PPT10.E.Wr$ߒM@yeѿh0( / 00DArialNew bb/bhb0bB 0xbDBook Antiquab/bhb0bB 0xb DWingdingsuab/bhb0bB 0xb0DTimes New Romanbhb0bB 0xb@ .  @n?" dd  !"#$%&'()*+,-./012345689:;<=>?@ABCDEGKHIJwork?Can intermediate care work?Problem faced Slide 10 Slide 11 Slide 12Aims of health care system? Major objectives of health careHospital careHospital care and activitiesWhat process is needed? Slide 18Structure neededCharacteristics of serviceNote Note - 2And Evidence EvidenceRehabilitation &_David WoodheadDavid WooSlide 27Two other differencesConclusion - 1ConcZOh+'0l `hx  Slide 1Wade 1Wade 110eMicrosoft PowerPointP@ ^ @`D@@w"EGr g  1E  --$--'. @Book Antiqua-42 NIntermediate care can not work$6%$$!3!".Courier New(z(dbj--.@Book Antiqua-!2 <Dr Derick T Wade, " #   , .-.@Book Antiqua-E2 Pc)Professor in Neurological Rehabilitation,   %      .-.@Book Antiqua-32 Oxford Centre for Enablement,a#    ( .-.@Book Antiqua-:2 a"Windmill Road, OXFORD OX3 7LD, UK, '  $#" # " " .-.@Book Antiqua- 2  Tel.-.@Book Antiqua-2 N: +44 .-.@Book Antiqua- 2 -.-.@Book Antiqua-2 (0)1865.-.@Book Antiqua- 2 G-.-.@Book Antiqua-2 V737310.-.@Book Antiqua- 2 O Fax.-.@Book Antiqua-2 OO: +44 .-.@Book Antiqua- 2 O-.-.@Book Antiqua-2 O(0)1865.-.@Book Antiqua- 2 OH-.-.@Book Antiqua-2 OW737309.-.@Book Antiqua-2 email'.-.@Book Antiqua- 2 : .-.@Book Antiqua--2 $derick.wade@dsl.pipex.com  &!  '.-Z՜.+,0XConclusion - 2{Rehabilitation should be embraced Clinically relevant Grounded in a logically coherent model Strongly supported by evidence0"ZZ!Rehabilitation does workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL}$ b $$(  $r $ S St `}  t r $ S St ` t H $ 0޽h ? 3380___PPT10.EO b h0(  hx h c $` `   x h c $p `   H h 0޽h ? 33$ b l$(  lr l S  `}   r l S E `  H l 0޽h ? 3380___PPT10.E@u* b p*(  pr p S Q `}   x p c $( `  H p 0޽h ? 3380___PPT10.E  b H@|(  |R | s *@ R | s *@ r | S     r | S p `  H | 0޽h ? 3380___PPT10.E@Bb$ b $(  r  S  `}   r  S  `  H  0޽h ? 3380___PPT10.E4@$ b $(  r  S Q `}   r  S [ `  H  0޽h ? 3380___PPT10.EI]$ b  $(  r  S # `}   r  S p= `  H  0޽h ? 3380___PPT10.E࠲ b 00(  x  c $   x  c $H `  H  0޽h ? ̙33r4! Kweo!|0( / 00DArialNew bb/bhb0bB 0xbDBook Antiquab/bhb0bB 0xb DWingdingsuab/bhb0lusion - 2Rehabilitation does work  Fonts UsedDesign Template Slide TitlesbB 0xb0DTimes New Romanbhb0bB 0xb@ .  @n?" dd@  @@`` 0%(   !(  !"# 0AApf@wʚ;ʚ;g4VdVdbB 0bppp@ <4ddddĶbpC 0b/b <4!d!dĶbhG 0bb80___PPT10 pp?  %*Intermediate care can not workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL} OutlineLinguistic, philosophical considerations Consideration of clinical problem faced Discussion of the solution needed Demonstration that the introduction of intermediate care was irrational and causes confusion rehabilitation, in contrast, is rational, works, and fulfils the clinical need:t Intermediate Coming or occurring between two things, places etc.  Occurring or coming between two points in time or events OED 2004(|6ECare< Burdened state of mind arising from fear  Serious or grave mental attention  Used of destitute ... Who is judged fit for official guardianship OED 2004Intermediate care A range of services at the interface between secondary care and primary care  .. Intended to reduce avoidable hospital admission .. Improve transition from hospital to home. From Steiner & Walsh RCT (BMJ 9/3/05)Intermediate care definitionsMay focus on: Stage in a pathway Degree of expertise Quantity of resources Location of service Intention of service There is no useful definitionf    Can Intermediate Care work?In the absence of any agreement whatsoever about the meaning of IC, and With different people and organisations including and excluding different things It is not possible to conclude that it works Because some people will say that something that is not IC is in fact responsible:R4     Aims of health care system?&To maximise social participation of patient maximise role function maximise social status To maximise well-being of patient somatic and emotional achieving satisfaction (adaptation) To minimise stress on & distress of relatives somatic and emotional-.":.-."..   Major objectives of health careREnsure that pathology is identified and any specific treatments given Then Maximise or optimise the patient s Behavioural repertoire (their activities) Ability to adapt to changes in life circumstances Environment (physical and social context) Minimise the patient s distress Minimise carer burdenfF#6F#6  Hospital careFocused (increasingly) on Pathology Diagnosis (assessment, investigation) Treatment (surgery, drugs) Monitoring (usually out-patient) Physiological (bodily) support ITU etc Processes are largely Short-term, quick Independent of context b) b ) Hospital care and activitiesNecessary support is given Toileting, feeding, washing, dressing Context (environment) is hostile Physically, socially, personally Minimal effort to help recovery Therefore left with a patient who cannot go home`&!!R&!!RWhat process is needed?. A problem-solving process Focused on activities Assessment (diagnosis, formulation) identification and analysis of problems Goal setting Interventions that are characteristically multi-focal, and spread over-time Reassessment (monitoring)0$(7"0   (7"  Structure neededA multi-disciplinary group of people who: work towards common goals for each patient involve and educate the patient and family have relevant expertise and knowledge can resolve most common problems In other words, a specialist teamz*"* Characteristics of servicePatient s disease is not the focus of action Importance of patient s social roles Emphasis on minimising stress/distress Consideration/involvement of family Multiple interventions & coordination Expertise and specialisation Presence of longer-term goals6';NotepNo mention of Location Management organisation Specific professions Timing/phase of illness Amount of resources 6bbNote - 2xStructures are inclusive Processes are generic Outcomes are broad Name for this service is R E H A B I L I T A T I O NX]   &AndRehabilitation does workEvidence Spinal cord injury success Systematic reviews and meta-analyses Stroke, multiple sclerosis, head injury etc Randomised, controlled studies Large parallel groups High level aspects Single case, case series More detailed aspects Controlled clinical trials (CCTs)@,"@, "EvidenceThe evidence supports the process, and says less about content Features: Expertise & specialism Problem-solving, educational approach Co-ordination Multi-professional Involvement of patient & family8I~(~U hRehabilitationIs intermediate illness management Between Pathology and person Hospital and home (and work) Beginning and end Health and other agencies J+^ ^ Rehabilitation Clear definition of structure, process and outcome Not defined or characterised by: Location Staff Organisation Time Age/diseaseBT- T- vIntermediate care No agreed definitions Variably charact-erised by: Location Staffing Organisation Time Age/diseaseB40 4045Two other differencesIntermediate care is politically defined and driven has no underlying logic or model Rehabilitation is clinically defined and driven is logically consistent and grounded in a coherent, agreed modelXCbCbConclusion - 1Intermediate care should be abandoned A political chimera, varying with circumstances Not coherent, and causes confusion Does not uniquely satisfy any clinical need Unsupported by the limited evidence available (1 trial) 0& Conclusion - 2{Rehabilitation should be embraced Clinically relevant Grounded in a logically coherent model Strongly supported by evidence0"ZZ!Rehabilitation does workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL} b  2(  r  S \t `}  t   S $I ` t H  0޽h ? 33___PPT10i.D'i+D=' b= @B + b @>(  r  S LO `}  t   S _ `  &x V { |H  0޽h ? 33___PPT10i.EV+D=' b= @B +rS57e:!y4( / 00DArialNew bb/bhb0bB 0xbDBook Antiquab/bhb0bB 0xb DWingdingsuab/bhb0bB 0xb0DTimes New Romanbhb0bB 0xb@ .  @n?" dd@  @@`` @' (   !(  !"#$% 0AApf@wʚ;ʚ;g4VdVdbB 08bppp@ <4ddddĶbpC 0b/b <4!d!dĶbhG 0bb80___PPT10 pp?  %.Intermediate care can not workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL} OutlineLinguistic, philosophical considerations Consideration of clinical problem faced Discussion of the solution needed Demonstration that the introduction of intermediate care was irrational and causes confusion rehabilitation, in contrast, is rational, works, and fulfils the clinical needN%A Intermediate Coming or occurring between two things, places etc.  Occurring or coming between two points in time or events OED 2004(|6ECare< Burdened state of mind arising from fear  Serious or grave mental attention  Used of destitute ... who is judged fit for official guardianship OED 2004Intermediate care A range of services at the interface between secondary care and primary care  .. Intended to reduce avoidable hospital admission .. Improve transition from hospital to home. From Steiner & Walsh RCT (BMJ 9/3/05)Intermediate care definitionsMay focus on: Stage in a pathway Degree of expertise Quantity of resources Location of service Intention of service There is no useful definition Melis et al BMJ 2004;329:360-361f?     "Does intermediate care work?mDepends upon expected outcome Only trial No major benefit Costed more Walsh et al, BMJ 2005;330: (9th March)j)')Can intermediate care work?In the absence of any agreement whatsoever about the meaning of IC, and With different people and organisations including and excluding different things It is not possible to conclude that it works Because some people will say that something that is not IC is in fact responsible:R4#  Problem facedIntermediate care was a politically driven solution to the (perceived)  problem of mainly elderly people staying in acute hospitals longer that some doctors and managers liked (and often the patients also wanted to move on) Need to consider nature      Aims of health care system?&To maximise social participation of patient maximise role function maximise social status To maximise well-being of patient somatic and emotional achieving satisfaction (adaptation) To minimise stress on & distress of relatives somatic and emotional-.":.-."..   Major objectives of health careREnsure that pathology is identified and any specific treatments given Then Maximise or optimise the patient s Behavioural repertoire (their activities) Ability to adapt to changes in life circumstances Environment (physical and social context) Minimise the patient s distress Minimise carer burdenfF#6F#6  Hospital careFocused (increasingly) on Pathology Diagnosis (assessment, investigation) Treatment (surgery, drugs) Monitoring (usually out-patient) Physiological (bodily) support ITU etc Processes are largely Short-term, quick Independent of context b) b ) Hospital care and activitiesNecessary support is given Toileting, feeding, washing, dressing Context (environment) is hostile Physically, socially, personally Minimal effort to help recovery Therefore left with a patient who cannot go home`&!!R&!!RWhat process is needed?. A problem-solving process Focused on activities Assessment (diagnosis, formulation) identification and analysis of problems Goal setting Interventions that are characteristically multi-focal, and spread over-time Reassessment (monitoring)0$(7"0   (7"  Structure neededA multi-disciplinary group of people who: work towards common goals for each patient involve and educate the patient and family have relevant expertise and knowledge can resolve most common problems In other words, a specialist teamz*"* Characteristics of servicePatient s disease is not the focus of action Importance of patient s social roles Emphasis on minimising stress/distress Consideration/involvement of family Multiple interventions & coordination Expertise and specialisation Presence of longer-term goals6';NotepNo mention of Location Management organisation Specific professions Timing/phase of illness Amount of resources 6bbNote - 2xStructures are inclusive Processes are generic Outcomes are broad Name for this service is R E H A B I L I T A T I O NX]   &AndRehabilitation does workEvidence Spinal cord injury success Systematic reviews and meta-analyses Stroke, multiple sclerosis, head injury etc Randomised, controlled studies Large parallel groups High level aspects Single case, case series More detailed aspects Controlled clinical trials (CCTs)@,"@, "EvidenceThe evidence supports the process, and says less about content Features: Expertise & specialism Problem-solving, educational approach Co-ordination Multi-professional Involvement of patient & family8I~(~U hRehabilitationIs intermediate illness management Between Pathology and person Hospital and home (and work) Beginning and end Health and other agencies J+^ ^ Rehabilitation Clear definition of structure, process and outcome Not defined or characterised by: Location Staff Organisation Time Age/diseaseBT- T- vIntermediate care No agreed definitions Variably charact-erised by: Location Staffing Organisation Time Age/diseaseB40 4045Two other differencesIntermediate care is politically defined and driven has no underlying logic or model Rehabilitation is clinically defined and driven is logically consistent and grounded in a coherent, agreed modelXCbCbConclusion - 1Intermediate care should be abandoned A political chimera, varying with circumstances Not coherent, and causes confusion Does not uniquely satisfy any clinical need Unsupported by the limited evidence available (1 trial) 0& Conclusion - 2{Rehabilitation should be embraced Clinically relevant Grounded in a logically coherent model Strongly supported by evidence0"ZZ!Rehabilitation does workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL}} b $$(  $r $ S St `}  t r $ S St ` t H $ 0޽h ? 33___PPT10i.EO+D=' b= @B + b @>(  r  S LO `}  t   S _ `  &x V { |H  0޽h ? 33___PPT10i.EV+D=' b= @B + b `>(  r  S 'gz     S  `  &x V { |H  0޽h ? 33___PPT10i.E`]+D=' b= @B +} b @$(  r  S  `}   r  S , `  H  0޽h ? 33___PPT10i.E Ѫ+D=' b= @B +} b p $(   r  S ˹ `}   r  S |̹ `  H  0޽h ? 33___PPT10i.E@{;+D=' b= @B +$ b P$(  r  S  `}   r  S  `  H  0޽h ? 3380___PPT10.ENr,:q0ntyJo" w| e:C~#5( / 00DArialNew bb/bhb0bB 0xbDBook Antiquab/bhb0bB 0xb DWingdingsuab/bhb0bB 0xb0DTimes New Romanbhb0bB 0xb@ .  @n?" dd@  @@`` @' (   !(  !"#$% 0AA f@wʚ;ʚ;g4VdVdbB 0bppp@ <4ddddĶbpC 0b/b <4!d!dĶbhG 0bb80___PPT10 pp?  %Q/Intermediate care can not workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL} OutlineLinguistic, philosophical considerations Consideration of clinical problem faced Discussion of the solution needed Demonstration that the introduction of intermediate care was irrational and causes confusion rehabilitation, in contrast, is rational, works, and fulfils the clinical needN%A Intermediate Coming or occurring between two things, places etc.  Occurring or coming between two points in time or events OED 2004(|6ECare< Burdened state of mind arising from fear  Serious or grave mental attention  Used of destitute ... who is judged fit for official guardianship OED 2004Intermediate care A range of services at the interface between secondary care and primary care  .. Intended to reduce avoidable hospital admission .. Improve transition from hospital to home. From Steiner & Walsh RCT (BMJ 9/3/05)Intermediate care definitionsMay focus on: Stage in a pathway Degree of expertise Quantity of resources Location of service Intention of service There is no useful definition Melis et al BMJ 2004;329:360-361f?     "Does intermediate care work?mDepends upon expected outcome Only trial No major benefit Costed more Walsh et al, BMJ 2005;330: (9th March)j)')Can intermediate care work?In the absence of any agreement whatsoever about the meaning of IC, and With different people and organisations including and excluding different things It is not possible to conclude that it works Because some people will say that something that is not IC is in fact responsible:R4#  Problem faced8Intermediate care was a politically driven solution to the (perceived)  problem of mainly elderly people staying in acute hospitals longer that some doctors and managers liked (and often the patients also wanted to move on) Need to consider nature of illness and health care systems*;;     Aims of health care system?&To maximise social participation of patient maximise role function maximise social status To maximise well-being of patient somatic and emotional achieving satisfaction (adaptation) To minimise stress on & distress of relatives somatic and emotional-.":.-."..   Major objectives of health careREnsure that pathology is identified and any specific treatments given Then Maximise or optimise the patient s Behavioural repertoire (their activities) Ability to adapt to changes in life circumstances Environment (physical and social context) Minimise the patient s distress Minimise carer burdenfF#6F#6  Hospital careFocused (increasingly) on Pathology Diagnosis (assessment, investigation) Treatment (surgery, drugs) Monitoring (usually out-patient) Physiological (bodily) support ITU etc Processes are largely Short-term, quick Independent of context b) b ) Hospital care and activitiesNecessary support is given Toileting, feeding, washing, dressing Context (environment) is hostile Physically, socially, personally Minimal effort to help recovery Therefore left with a patient who cannot go home`&!!R&!!RWhat process is needed?. A problem-solving process Focused on activities Assessment (diagnosis, formulation) identification and analysis of problems Goal setting Interventions that are characteristically multi-focal, and spread over-time Reassessment (monitoring)0$(7"0   (7"  Structure neededA multi-disciplinary group of people who: work towards common goals for each patient involve and educate the patient and family have relevant expertise and knowledge can resolve most common problems In other words, a specialist teamz*"* Characteristics of servicePatient s disease is not the focus of action Acknowledges importance of patient s social roles Emphasis on minimising stress/distress Consideration/involvement of family Multiple interventions & coordination Expertise and specialisation Presence of longer-term goals8 Z';NotepNo mention of Location Management organisation Specific professions Timing/phase of illness Amount of resources 6bbNote - 2xStructures are inclusive Processes are generic Outcomes are broad Name for this service is R E H A B I L I T A T I O NX]   &AndRehabilitation does work(Evidence Spinal cord injury success Systematic reviews and meta-analyses Stroke, multiple sclerosis, head injury etc Randomised, controlled studies Large parallel groups High level aspects Single case, case series More detailed aspects Controlled clinical trials (CCTs)@,"@, "EvidenceThe evidence supports the process, and says less about content Features: Expertise & specialism Problem-solving, educational approach Co-ordination Multi-professional Involvement of patient & family8I~(~U hRehabilitationIs intermediate illness management Between Pathology and person Hospital and home (and work) Beginning and end Health and other agencies J+^ ^ Rehabilitation Clear definition of structure, process and outcome Not defined or characterised by: Location Staffing, resources Organisation Time Age/diseaseBT; T; Intermediate care No agreed definitions Variably charact-erised by: Location Staffing, resources Organisation Time Age/diseaseB4; 4;4@Two other differencesIntermediate care is politically defined and driven has no underlying logic or model Rehabilitation is clinically defined and driven is logically consistent and grounded in a coherent, agreed modelXCbCbConclusion - 1Intermediate care should be abandoned A political chimera, varying with circumstances Not coherent, and causes confusion Does not uniquely satisfy any clinical need Unsupported by the limited evidence available (1 trial) 0& Conclusion - 2{Rehabilitation should be embraced Clinically relevant Grounded in a logically coherent model Strongly supported by evidence0"ZZ!Rehabilitation does workDr Derick T Wade, Professor in Neurological Rehabilitation, Oxford Centre for Enablement, Windmill Road, OXFORD OX3 7LD, UK Tel: +44-(0)1865-737310 Fax: +44-(0)1865-737309 email: derick.wade@dsl.pipex.comL}} b P$(  r  S  `}   r  S  `  H  0޽h ? 33___PPT10i.EN+D=' b= @B + b `\0(  \x \ c $d `j   x \ c $8'g<  H \ 0޽h ? 33___PPT10i..X+D=' b= @B + b p`(  `r ` S $ `}   r ` S % `  d ` <)) VvH ` 0޽h ? 33___PPT10i.EbP\+D=' b= @B +} b d$(  dr d S 8t `}  t r d S 9t ` t H d 0޽h ? 33___PPT10i.E.W+D=' b= @B +1 b H@|(  |R | s *@ R | s *@ r | S     r | S p `  H | 0޽h ? 33___PPT10i.E@Bb+D=' b= @B +r(~0@Ѹ»G#ew~#Root EntrydO) TF~Current UserF/SummaryInformation( PowerPoint Document(Jd  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIeMNOPQRSTUVWXYZ[\]^_`afghijklmnopqrstuvwxyz{L  !"#$%&'()*+,-./012345689:;<=>?@ABCDEGHIJwork?Can intermediate care work?Problem faced Slide 10 Slide 11 Slide 12Aims of health care system? Major objectives of health careHospital careHospital care and activitiesWhat process is needed? Slide 18Structure neededCharacteristics of serviceNote Note - 2And Evidence EvidenceRehabilitation _hire4hire4Slide 27Two other differencesConclusion - 1Conclusion - 2Rehabilitation does work  Fonts UsedDesign Template Slide Titlesdhead