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Intermediate Care
Gesundheits- und Fürsorgedirektion des Kantons Bern (Department of Health and Social Welfare)
Switzerland

The Problem

Solution and Key Benefits

 What is the initiative about? (the solution)
Our objectives were to compare post-acute intermediate care in an inpatient setting of an acute hospital with conventional care on general medical wards. We did a non-randomised clinical study without matching of patients, but similar structures in acute care, with six month follow up, in three Regional Hospital Centres, with 1054 patients as participants accepted for admission to intermediate care.
Main outcome measures were patient’s functional status, readmission to hospitals, kind and frequency and costs of services provided, demand for intermediate care.
Patient’s functional status, as measured by the ability to perform activities of daily living (Barthel index) and health-related disabilities (WHODAS II), showed better results for intermediate care, even 3 months after discharge. The patients returned home almost twice as frequently, required less support from home healthcare services, almost never needed subsequent rehabilitation or health resort cure and only required further institutional care in an old people's or nursing home half as often as the control group.
The daily service costs for intermediate care were a good 25% below those for conventional care, and even the total costs per treated case were slightly lower than for conventional treatment. The average number of services per patient per day was approximately half as high as in the control group. The period of care in the intervention groups was comparatively high (13 days on average compared to 7 days in the control group).
Instead of medical consultations, para-medical services predominated in the intervention groups, particularly physiotherapy and thorough preparation for the return home.
A cautious estimate shows that around 2.2% of all patients, or 9.5% of over 75-year old patients, could require such treatment, i.e. approximately 4,500 to 5,000 patients a year in the canton of Bern.
Intermediate care satisfies the criteria of effectiveness, efficacy and expediency. However, a fundamental decision for a canton-wide introduction of intermediate care involves a change in the system and requires further preparation.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
On 1 March 2003, the Department of Health and Social Welfare of the Canton of Bern initiated a model intermediate care trial involving the Erlenbach Clinic and Frutigen Hospital and – for comparative purposes – Burgdorf Regional Hospital. During a 20-month test phase, the advantages and disadvantages of a specific intermediate care facility in association with an acute hospital stay were examined in terms of costs and quality.

The survey of the participating facilities was concluded in December 2004. Complementary data for the year 2004 were available from the Medical Statistics of the Federal Office for Statistics by mid-2005, and the statistical evaluation of the model trial was completed by the start of November 2005.

We hope to integrate a corresponding scenario into the ongoing Service Provision Planning 2007-2010 of the Canton of Bern.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
In Switzerland, a recently introduced system of departmental fixed payments (Abteilungsfallpauschalen) has made an effective contribution to shorter stays in acute hospitals, principally because – as intended – the hospitals have reduced time and efforts incurred in order to make their fixed payments more cost effective.

At the same time, a number of hospitals are now experiencing bed shortages in their acute departments. But if the early discharge of a patient is not medically acceptable, the patient is often referred to a rehabilitation clinic even if he or she is not in need of rehabilitation, or not yet in a fit state to undergo rehabilitation at the time of the transfer.

This situation explains the evident growth in the demand for a local in-patient facility that provides the necessary, predominantly nursing, care before the patient can return home. Such a facility formed the subject of this model trial on intermediate care.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The Department of Health and Social Welfare of the Canton of Bern particularly wanted to obtain information about the following aspects from the model trial:
-specific indications for intermediate care
-necessary resources in terms of medical, therapeutic, nursing care and duration of treatment
-cost advantages/disadvantages
-quality related advantages/disadvantages compared to conventional treatment.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The specific intermediate care model reduces the number of treatments by doctors, with instead the predominance of non-medical services of various kinds. The differences in the care provided were evidently less of a quantitative and more of a qualitative nature: para-medical services predominated in the intermediate care intervention groups, particularly physiotherapy and thorough preparation for the return home.

In difference to conventional care on a general medical ward in an acute hospital the priorities in intermediate care are

to pass on support and confidence for every day life
-by focussing on planning the discharge
-by domiciliary visits and therapies based on their results
-by a close cooperation with relatives and home healthcare services

to build up the patient’s motivation
-by a long term definition of aims
-by a step by step mobilization.

Therefore intermediate care develops and claims for a specialisation in the sense of
-an orientation primarily on the patient’s individual psychosocial needs
-an other dynamic (slow down).

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Quality-related advantages and disadvantages (effectiveness):
The evaluation of the quality-related aspects showed distinctly positive results for the intermediate care model. The health dimension, as measured by the ability to perform activities of daily living (Barthel index) and health-related disabilities (WHODAS II), showed better results compared to the control group, even in the long term, i.e. 3 months after discharge. After intermediate care, the patients returned home almost twice as frequently, required less support from home healthcare services, almost never needed subsequent rehabilitation or health resort cure and only required further institutional care in an old people's or nursing home half as often.

Cost-related advantages and disadvantages (efficacy):
The daily service costs for intermediate care were a good 25% below those for conventional care, and even the total costs per treated case were slightly lower than for conventional treatment. This is all the more remarkable in view of the comparatively long stays involved in intermediate care.

Input of care (expediency):
The average number of services per patient per day was approximately twice as high in the control group compared to the intervention groups. On the other hand, the period of care in both intervention groups was comparatively high (13 days on average compared to 7 days in the control group). Taking into account the longer stays in the intervention groups, the differences in the input of care are less of a quantitative and more of a qualitative nature: instead of medical consultations, para-medical services predominated in the intervention groups, particularly physiotherapy and thorough preparation for the return home.

Demand for intermediate care:
The demand for intermediate care cannot yet be quantified on the basis of currently available data, although all three participating institutions confirmed that such a demand existed. A preliminary cautious estimate based on extrapolation of the data from the participating institutions shows that around 2.2% of all patients, or 9.5% of over 75-year old patients, could require such treatment, i.e. approximately 4,500 to 5,000 patients a year in the canton of Bern.

Overall evaluation of the intermediate care pilot trial:
In view of the resulting picture – better health in the two intervention groups with a slightly longer stay, but comparable overall costs – intermediate care can be summed up as follows: "substantial health benefit with a slightly higher care input but identical overall costs".

Sustainability and Transferability

  Is the initiative sustainable and transferable?
At the present time it can be stated that intermediate care satisfies the criteria of effectiveness, efficacy and expediency. However, a fundamental decision for a canton-wide introduction of intermediate care involves a change in the system and requires thorough preparation. We hope to integrate a corresponding scenario into the ongoing Service Provision Planning 2007-2010 of the Canton of Bern as follows:

Intermediate care is to be integrated into the Regional Hospital Centres as a nucleus and part of the basic services. Other than e. g. rehabilitation it is not meant to generate an own new tariff but is to be financed as part of the acute care within the framework of the DRG-based tariff.

The Regional Hospital Centres are obliged to organize their service in intermediate care in either an internal or external setting. Organizational forms may be a service within the same location, at another location within the same Regional Hospital Centre, in cooperation with another Regional Hospital Centre or with a rehabilitation clinic. Generally intermediate care has to take place within an own separate unit and to fulfil the demands for infrastructure und quality defined by the Department of Health and Social Welfare of the Canton of Bern. If a patient is transferred to an external institution for intermediate care, the institutions involved settle the costs within the framework of the tariff for acute care.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The model trial in general took place under certain limitations:
There was no refunding whatsoever for taking part in the trial except a small amount for gathering the data. For this reason several hospitals refrained from participating – of formerly a dozen interested in the trial there remained only two.

These two hospitals worked with different settings, with a different organizational mode for intermediate care. The clinic in Erlenbach provided a separate unit exclusively meant for patients in intermediate care, whereas the hospital in Frutigen could only offer some beds within a unit for conventional care on a general medical ward.

Methods in gathering data also differed in the hospitals involved. As to the “WHODAS II” questionnaire, Burgdorf and Frutigen used the self-administered version as a rule, Erlenbach tended to use the proxy version with data filled in by the nurses. Furthermore we met some difficulties in tracing “our” patients in the official Medical Statistics for Hospitals, and ended up with only 80% hits. There obviously was a certain lack in codification from our side.

Opposite to initial intentions we could not further investigate the meaning of intermediate care in terms of extended or enhanced roles for nurses. Other than in the UK, nurse-led care units are rare to non-existent within the Swiss health care system. But the model trial surely can be seen as a step in the direction of extension: The trial was primarily led by nurses, being responsible for the data collection, pointing out patients apt for intermediate care and developing a specific conceptual framework of caring. We found that the nurses derived satisfaction from their work under the circumstances, but we were not able to follow this up more precisely.

As a result of these limitations there remain some restrictions to the interpretation of our data, some questions unanswered:

For example no statistically relevant differences were found in relation to the two different settings mentioned above. So we only can assume that one is superior to the other.

Concurrent with most of the literature the trial showed that intermediate care is a “good thing” predominantly for older people. Our „typical“ intermediate care patient was - in respect to age and multimorbidity - very close to what could be defined as a geriatric patient. Therefore there remains some work to be done to define appropriate patient’s pathways either to intermediate care or to a geriatric rehabilitation.

Contact Information

Institution Name:   Gesundheits- und Fürsorgedirektion des Kantons Bern (Department of Health and Social Welfare)
Institution Type:   Government Department  
Contact Person:   Christa Brunswicker
Title:   Scientific Collaborator  
Telephone/ Fax:   ++41 31 633 79 79
Institution's / Project's Website:   ++41 31 633 79 67
E-mail:   christa.brunswicker@gef.be.ch  
Address:   Rathausgasse 1
Postal Code:   3011
City:   Bern
State/Province:  
Country:   Switzerland

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