Intermediate care is an emerging concept in health care, which may offer attractive alternatives to hospital care for elderly patients. As little scientific evidence exists on the benefits of intermediate care, research is especially important.1-3 A prerequisite for research is agreement on the definition of a concept, which is lacking for intermediate care. The term intermediate care is often used as if its meaning is clear, but it conveys little meaning other than being about care that is “in between.” Commonly used definitions of intermediate care do not help much, and several very different definitions are in use. What is needed at the outset is a consensus on what constitutes intermediate care. Until this is agreed on, the concept of intermediate care will remain a mirage and its possibilities unknown.
The term intermediate care was introduced in the United Kingdom's NHS Plan and refined in the national service framework for older people.4,5 The concept seems to arise out of a policy imperative, rather than an analysis of the scientific evidence about effective models of care. Objectives such as “promotion of independence” and “prevention of unnecessary hospital admission” were to be achieved through providing a new range of services between hospital and home. Specific targets (for example, the number of service users, prevented admissions) accompanied these objectives. However, no particular models of service delivery were defined.
Professional statements of good practice followed the political decision that reconfiguration of the health service would include investment in intermediate forms of care. The British Geriatrics Society listed three definitions in its statement on intermediate care.1 The broadest definition is the one shared with the Royal College of Physicians of London, according to which intermediate care is delivered by those health services that do not require the resources of a general hospital but are beyond the scope of the traditional primary care team.2
Recently, Andrea Steiner published as many as eight definitions of intermediate care.6 Five of them (partly) focused on facilitating the transition from hospital to home. Other aims include avoidance of admission and improvement of pre-acute and post-acute care. A systematic review on the best place of care for older people after acute illness concluded that service models were best described in terms of the objectives of care.7
Definitions from the databases Medline and CINAHL narrow intermediate care in the direction of nursing home care. For example, in Medline “intermediate care facilities” are institutions that provide health related care and services to individuals who do not require the degree of care which hospitals or skilled nursing facilities provide, but require care and services above the level of room and board. This probably results from the existence of intermediate care facilities in the United States and Japan, which closely resemble nursing homes. Further difficulty arises because individual authors also use the term intermediate care when describing a less advanced type of intensive care medicine.8
This inventory of definitions shows that the term intermediate care currently does not present imply a specific, well defined type of health care (box). This worrying conclusion has important consequences. To compare results of research projects will be difficult if not impossible, as will be identifying gaps in our current knowledge or critically appraising the benefits attributed to intermediate care. These difficulties will only increase because of the growing popularity of alternatives to hospital inpatient care across Europe and the rest of the world.
Definitions of intermediate care
British Geriatrics Society1
An approach to health care intended to facilitate patients' transitions from illness to recovery, or to prevent their transition from home managed chronic impairment to institution-based dependence, or to help terminally ill people be as comfortable as possible at the end of their lives
That range of services designed to facilitate transition from hospital to home, and from medical dependence to functional independence, where the objectives of care are not primarily medical, the patients' discharge destination is anticipated, and a clinical outcome of recovery (or restoration of health) is desired
Those services that do not require the resources of a general hospital, but are beyond the scope of the traditional primary care team. These can include “substitutional care” and “care for people with complex needs”
(The last definition is the same as the one the Royal College of Physicians uses in its statement2)
Medical subject heading (MeSH)9
• Intermediate care facilities are institutions that provide health related care and services to individuals who do not require the degree of care that hospitals or skilled nursing facilities provide, but because of their physical or mental condition require care and services above the level of room and board
CINAHL subject headings
Intermediate care (see subacute care) is care provided to acute care patients who are medically stable but too unstable to be treated in alternative healthcare settings such as home, ambulatory, or traditional skilled long term care
Intermediate care facilities: entered here are materials on nursing home facilities. For care given in a nursing home, see long term care
To deal with this Babel of voices we suggest a formal process to develop a consensus of the key elements of intermediate care. The aim of this debate should not be to arrive at a uniform definition of intermediate care, for our inventory on the definitions of intermediate care has shown that it is impossible to define intermediate care unequivocally at the highest conceptual level. For reasons of simplicity, this debate should be limited to defining intermediate care for the purpose of scientific appraisal. It would also be helpful if bibliographers were able to establish a consensus for terminology, such as medical subheadings.9 For the time being we believe that intermediate care models can be best classified according to their objectives of care and not by their names. If we do not clearly define key elements of the concept of intermediate care, then it will remain a concept with unfulfilled promise.
Competing interests: None declared.
References
- 1.Intermediate care. Guidance for commissioners and providers of health and social care. (BGS compendium document D4). London: British Geriatrics Society, 2001. www.bgs.org.uk/compendium/comd4.html (accessed 6 May 2004).
- 2.Black C, Black D, Alberti G. Intermediate care: statement from the Royal College of Physicians of London. London: Royal College of Physicians 2000. www.rcplondon.ac.uk/college/statements/statements_interm_care.htm (accessed 22 Jun 2004).
- 3.Carpenter I, Gladman J, Parker S, Potter J. Clinical and research challenges of intermediate care. Age Ageing 2002;31: 97-100. [DOI] [PubMed] [Google Scholar]
- 4.Department of Health. The NHS plan. A plan for investment, a plan for reform. London: Stationery Office 2000. www.nhs.uk/nationalplan/ (accessed 6 May 2004).
- 5.Department of Health. The national service framework for older people. London: DoH, 2001. www.dh.gov.uk/assetRoot/04/07/12/83/04071283.pdf (accessed 22 Jun 2004).
- 6.Steiner A. Intermediate care—a good thing? Age Ageing 2001;30(suppl 3): 33-9. [DOI] [PubMed] [Google Scholar]
- 7.Parker G, Bhakta P, Katbamna S, Lovett C, Paisley S, Parker S, et al. Best place of care for older people after acute and during subacute illness: a systematic review. J Health Serv Res Policy 2000;5: 176-89. [DOI] [PubMed] [Google Scholar]
- 8.Junker C, Zimmerman JE, Alzola C, Draper EA, Wagner DP. A multicenter description of intermediate-care patients: comparison with ICU low-risk monitor patients. Chest 2002;121: 1253-61. [DOI] [PubMed] [Google Scholar]
- 9.US National Library of Medicine. 2003 Medical subject heading, annotated alphabetic list. Springfield, Virginia: National Technical Information Services 2003. www.nlm.nih.gov/mesh/meshhome.html (accessed 6 May 2004).