Background and context

Intermediate care is a collective term for short-term interventions that aim to maximise people’s independence and quality of life following or during a period of illness. It includes ‘step-down’ services after discharge from an episode of acute care to support recovery and ‘step-up’ services to avoid admission to hospital. Intermediate care commonly involves rehabilitation, reablement and recovery support and can be provided in a person’s home or in a community bedded setting.

This guidance is for all staff involved in collecting and submitting data to the Intermediate care data collection, the new name for the COVID-19 EPRR Community Daily Discharge Situation Report (SitRep) established in June 2020 to support the COVID-19 national response. It also acts as a guide for managers or duty directors who hold responsibility for signing off weekly data reports and/or overseeing the supervision of the processes for clinical data collections.

As well as renaming this collection, we have revised the question set (see Annex A for a summary of these changes) to reflect policy changes and ensure alignment with the intermediate care framework published in October 2023. We worked with a range of stakeholders including regions, integrated care boards, providers, clinicians and policy leads to develop the new question set.

These changes shift the focus of the collection from solely discharge to reporting on numbers of patients received into services; access to rehabilitation and reablement; and approximate length of stay in services.

Providers are expected to collect data in accordance with the revised question set from 29 July 2024.

The collected data supports local demand and capacity planning, including Better Care Fund planning returns. Nationally and regionally, it provides oversight of intermediate care access and highlights blockages in patient flow. Triangulated with data from the Urgent and emergency care (UEC) and Acute discharge SitReps, it informs national, regional and system-wide discussions about service delivery, and supports collaborative working and conversations, both for day-to-day operations and local improvement work. As such, while the responsibility for submitting the data lies with trusts, staff should work with colleagues across the system, including from local authorities, to compile and use it.

The data collection is covered by the COVID-19 Situation Reports Data Provision Notice, which requires data to be submitted weekly via the Strategic Data Collection Service (SDCS) portal. Submitters are asked to note that, while the collection name has changed to the Intermediate care data collection, for the purposes of the Strategic Data Collection Service (SDCS) portal the reference name remains ‘CommunityDailyDischargeSitRep’.

Most questions require the collection of daily information; the discharge delay reasons and length of stay questions are exceptions and require a weekly snapshot to be provided.

Intermediate care data is published monthly on the NHS England website.

Scope of the collection

In scope – providers

The submission template should be populated by all organisations providing NHS and/or jointly commissioned non-specialist community bedded services for the purposes of rehabilitation, reablement and recovery, including those funded through the BCF. This includes all NHS and jointly commissioned community beds that could be provided by, for example:

• community trusts
• community interest companies (CIC) and other providers of rehabilitation, reablement and recovery services within community bedded services
• acute trusts that also provide community services (reporting only their community hospital beds in this data collection)
• mental health trusts that also provide community services (reporting only their community hospital beds in this data collection)
• care homes where rehabilitation, reablement and recovery services are provided

Block contract and spot purchase beds are included in the above categories.

In scope – types of beds

The scope of this data collection includes all NHS, jointly commissioned and BCF-funded beds used for intermediate care purposes. The following list of bed types is not exhaustive, noting that local terminology for intermediate care beds may vary:

• intermediate care
• Pathway 2 (P2)
• transition
• step-down
• step-up
• discharge to assess (D2A)
• rehabilitation
• community beds for short-term services such as stroke, neuro rehabilitation and spinal recovery where they are not part of specialist funded rehabilitation

Rehabilitation, reablement and recovery beds provided through specialised commissioning services should be excluded.

Data submission

Deadline for returns

Completed templates should be submitted via the SDCS portal by midday (12:00 hours) each Tuesday.

Weekly reports must be signed off by a duty director or another senior manager appointed to this role by the provider’s chief executive. It is each community provider’s responsibility to ensure its return is accurate and reflects the validated position for the relevant time period.

Submission template

The Excel submission template is available to download from the SDCS when the reporting period is open. This contains data validations to ensure standardisation and good quality data from all submitters. The SDCS provides guidance on submitting data.

Data submitters are asked to note that, although the name of the collection has changed to the Intermediate care data collection, it builds on an existing collection and therefore the reference in the SDCS portal remains ‘CommunityDailyDischargeSitRep’.

A copy of the submission template is available on the Intermediate care FutureNHS platform. Users will need to register to access this platform and then to join the data community of practice by emailing england.intermediatecare@nhs.net

Workbook tool

We have produced an Excel workbook to help providers complete the data return and will send it to those who hold provider responsibility for submissions. The workbook enables rapid data collection following morning and afternoon board rounds under the guidance of clinicians, to keep the burden to a minimum. It is offered as a tool for internal data collection purposes, but providers can and may prefer to use other systems they already have in place. The workbook is also available on the Intermediate care FutureNHS platform.

Further supporting guidance

A regularly updated Q&A document can be found on the Intermediate care FutureNHS platform along with all of the supporting guidance and templates detailed in this document.

Specific guidance for each question is given below.

We recognise that different localities may use different terminology. Annex B provides guidance on the interpretation of terminology in the context of this data collection.

Contacts

• Technical enquiries: england.nhsdata@nhs.net
• Data submissions and SDCS queries: data.collections@nhs.net
• Intermediate care policy queries: england.intermediatecare@nhs.net
• To access the FutureNHS platform and/or to register to join the data community of practice: england.intermediatecare@nhs.net

Specific guidance notes for each question

Question 1

a) How many NHS or jointly commissioned intermediate care beds were available at 23.59 hours or the latest point your system collects the data (including vacant, reserved and occupied)?

b) Of those beds, how many were occupied at 23.59 hours or the lasts point your system collects data?

Frequency of collection and submission

Data for this question should be collected daily and submitted weekly via the SDCS portal.

This is a mandatory field and must be completed to submit the template.

Timing of data collection

This is daily retrospective data for the 24-hour period on the day specified on the submission template taken at 23.59 hours. We recognise that not all systems support reporting at 23.59. If your system does not, for questions 1a and 1b please take the data at the latest point your system is scheduled to collect.

Using the template

The data should be captured under the relevant day on the template – that is, the data collected at 23.59 on a Wednesday will be added into the template on a Thursday but entered in the column marked Wednesday.

Question 2

How many people were admitted into your intermediate care service over the 24-hour period on the day specified on the submission template?

Frequency of collection and submission

Data for this question should be collected daily and submitted weekly via the SDCS portal.

This is a mandatory field and must be completed to submit the template.

Timing of data collection

This is daily retrospective data for the 24-hour period on the day specified on the submission template taken at 23.59 hours. We recognise that not all systems support reporting at 23.59. If your system does not, for questions 2 please take the data at the latest point your system is scheduled to collect.

Using the template

The data should be captured under the relevant day on the template – that is, the data collected at 23.59 on a Wednesday will be added into the template on a Thursday but entered in the column marked Wednesday.

Question 3

Of the number of people who met the requirements to remain in your intermediate care service (criteria to reside) which of the following categories best described their requirements at the point of clinical review or the latest point your system collects the data?

a) low clinical risk; low rehab and/or reablement needs
b) low clinical risk; high rehab and/or reablement needs
c) high clinical risk; low rehab and/or reablement needs
d) high clinical risk; high rehab and/or reablement needs

Frequency of collection and submission

Data for this question should be collected daily and submitted weekly via the SDCS portal.

This is a mandatory field and must be completed to submit the template.

Timing of data collection

This data should be collected daily at the point of clinical review of the individual. We acknowledge that not every individual is reviewed every day. On days where an individual is not reviewed, their status should be recorded as it was on the previous day (no change) until the next review.

Additional guidance

This question is based on a summary of the Pathway 2 clinical criteria to reside sub-categories. The wording has been simplified in recognition of the range of staff members who might collect this information for data submission purposes. The high/low definitions act as guidance for assessment of the rehabilitation, reablement and recovery needs as set out in the good practice model developed in December 2022. The simplified summary definitions can be mapped onto most needs assessment methodologies.

Sub-categories of pathway 2 criteria to reside

Showing rehab complexity and nursing acuity scales
Note that these scales are examples and other assessment scales may be used as agreed locally

Key:

• Level 1 and 2 rehabilitation
• Rehab complexity score extended (RCS-E)
• Shelford Nursing Acuity
• Dependency (NPDS)

Image text:
P2c: Clinical risk is too high to go home at this stage. But relatively low rehab complexity
Examples of relevant assessment scores

• Rehab Complexity Score: 7-9
• Shelford Nursing Acuity: 0
• Dependency (NPDS): Medium high to very high

P2d: Both clinical risk and rehab requirements are high (but not reaching requirement for specialist inpatient rehabilitation)
Examples of relevant assessment scores

• Rehab Complexity Score: 8 – 11
• Shelford Nursing Acuity: 1
• Dependency (NPDS): Any score – low to very high

P2a: Current dependency, rehabilitation of cognition mean not yet able to be managed in community although medically stable, cognitively and physically able to participate in restorative activities
Examples of relevant assessment scores

• Rehab Complexity Score: 7 – 9
• Shelford Nursing Acuity: 0
• Dependency (NPDS): Medium high to very high

P2b: Hight rehab complexity than P2a (but not reaching requirement for specialist inpatient rehabilitation) although medically stable, acle to participate in comprehensive rehabilitation programme
Examples of relevant assessment scores

• Rehab Complexity Score: 8 – 11
• Shelford Nursing Acuity: 0
• Dependency (NPDS): Any score – low to very high

The full model can be found on the Community rehabilitation FutureNHS platform. To request access to the Community health services workspace on FutureNHS, please contact: england.communityservices1@nhs.net

Question 4

Of those people identified in Q3, how many were in the following stages of the process to receive rehabilitation, reablement and recovery services at 23.59 hours or the latest point your system collects the data?

a) the number of people who had not yet been assessed for their needs
b) the number of people who had been assessed and were waiting to start
c) the number of people who were receiving services

Frequency of collection and submission

Data for this question should be collected daily and submitted weekly via the SDCS portal.

This is a mandatory field and must be completed to submit the template.

Timing of data collection

The data should provide a daily snapshot of the number of people in each of the 3 stages of receiving rehabilitation, reablement and recovery services. The data should be collected at a consistent point in time during the day that fits with your internal processes.

Additional guidance

Further explanation of options 4a–c:

4a. The number who have not yet been assessed for their rehabilitation, reablement and recovery needs: this includes all people who have yet to have an initial therapy assessment (for community hospital/inpatient rehabilitation wards) and therapy goals set and all people who have yet to have an initial assessment (for care home-based service).

4b. The number assessed and waiting for rehabilitation, reablement and recovery services: this includes all people who have had an initial therapy assessment (for community hospital/inpatient rehabilitation wards) with goals set, but are yet to commence their active rehab/reablement/recovery plan, and all people who have had an initial assessment (for care home-based service) with goals set, but are yet to commence their active rehab/reablement/recovery plan.

4c. The number receiving rehabilitation, reablement and recovery services: this includes all people currently participating in an active rehab/reablement/recovery plan with agreed therapy goals.

People arriving into some intermediate care services will already have been assessed for their rehabilitation, reablement and recovery needs. They may, therefore, start receiving these services immediately on admission. In this case, individuals should be counted in 4c) The number receiving services.

Question 5

a) The number of people who did not meet the requirements to remain in an intermediate care service (criteria to reside) in the 24-hour period on the day specified on the submission template?
b) Of the people identified in Q5a, the number who left your service in the 24-hour period on the day specified on the submission template?
c) Of the people identified in Q5b, how many left via the following routes?

1. Pathway 0 – Discharged to a domestic home, hotel or other temporary accommodation without the need for new/increased care or support from health and social care
2. Pathway 0 – Discharged back to an original care home placement when the care home has confirmed they can continue to meet the person’s needs with the same level of support
3. Pathway 1 – Discharged to a domestic home, hotel or other temporary accommodation, or hospice at home with a new/increased care package to manage long-term care needs
4. Pathway 1 – Discharged to a domestic home, hotel or other temporary accommodation, or hospice at home to continue with rehabilitation, reablement and recovery
5. Pathway 1 – Discharged to a domestic home, hotel or other temporary accommodation, or hospice at home to continue with rehabilitation, reablement and recovery and with the support of a care package
6. Pathway 1 – Discharged back to original care home placement to continue with rehabilitation, reablement and recovery or with an increased level of support
7. Pathway 2 – Transferred to other non-acute bedded care for ongoing treatment
8. Pathway 3 – Discharged to a care home as a new admission
9. Pathway 3 – Discharged to a care home/hospice as a new admission for end-of-life care
10. Person has been admitted into an acute hospital bed including a virtual ward
11. Person has died

Frequency of collection and submission

Data for this question should be collected daily and submitted weekly via the SDCS portal.

This is a mandatory field and must be completed to submit the template.

Timing of data collection

This is daily retrospective data for the 24-hour period on the day specified on the submission template taken at 23.59 hours. We recognise that not all systems support reporting at 23.59. If your system does not, for questions 5a, 5b and 5c please take the data at the latest point your system is scheduled to collect.

Using the template

The data should be captured under the relevant day on the template – that is, the data collected at 23.59 on a Wednesday will be added into the template on a Thursday but entered in the column marked Wednesday.

Additional guidance

The guidance for Question 3 provides further details of the requirement to remain (criteria to reside) in an intermediate care bed.

You should count all people who left your service, including all discharges and transfers into other intermediate care (P2) services, as well as anyone admitted to an acute setting and anyone who has died.

Question 6

This question is based on a weekly snapshot at 23.59 hours or the latest point your system collects the data, on the same day each week to fit in with your internal processes.

Of the number of people identified in Q5a who did not leave your services:

a) How many days in total have they remained in your service since not meeting the requirements to remain in intermediate care services (criteria to reside)?
b) What is the reason, selecting from the following list, for why they continue to remain in your intermediate care service (select one primary reason)?

1. Awaiting a clinical (medical or nursing) decision/intervention including writing the discharge summary
2. Awaiting a therapy decision/intervention to proceed with discharge, including writing onward referrals, equipment ordering
3. Awaiting medicines to take home
4. Awaiting transport
5. Remains in non-specialist community bed to avoid spread of infectious disease and because no suitable location to discharge to
6. Individual/family concerns over discharge plans or readiness
7. Safeguarding concern or Court of Protection preventing discharge
8. Awaiting assessment of longer-term care needs
9. Awaiting outcome of decision on eligibility for funding under:
   1. Continuing Healthcare
   2. Care Act assessments
10. Awaiting organisation of a care package via the Care Transfer Hub or local brokerage services
11. Awaiting housing arrangements due to homelessness
12. Homeless with no recourse to public funds
13. Pathway 1: awaiting availability of resource for start of long-term care package at home (not a continuation of rehabilitation, reablement and recovery)
14. Pathway 1: awaiting availability of resource for continuation of rehabilitation, reablement and recovery support at home
15. Pathway 2: awaiting availability of another rehabilitation, reablement and recovery bed in a community bedded setting
16. Pathway 3: awaiting availability of a bed in a care home as a permanent placement
17. Pathway 3: awaiting availability of a bed in a care home for end-of-life care
18. Awaiting planned admission to an acute bed
19. Awaiting equipment
20. Awaiting adaptations to housing

Frequency of collection and submission

Data for this question should be collected daily and submitted weekly via the SDCS portal.

This is a mandatory field and must be completed to submit the template.

Timing of data collection

The data should provide a snapshot of reasons why people are delayed from leaving services on 1 day of the reporting period. The data should be collected on the same day each week to fit with your internal processes.

Additional guidance

This data captures everyone who no longer meets the requirement to be in an intermediate care service (criteria to reside), but has not left/been discharged. The cohort is the number of people identified in Q5a minus those captured as leaving in Q5b.

The collection includes everyone who is delayed regardless of their length of stay. Therefore, delays of 1 day or longer should be captured. Within an aggregate dataset it is only possible to collect one response to this question without significantly increasing data submission burden. So, while we recognise that there can be multiple factors delaying a person’s discharge, this question asks for what is considered to be the primary reason.

Question 7

This question is based on a weekly snapshot at 23.59 hours, or the latest point your system collects the data, on the same day each week to fit with your internal processes and records the total number of people in your intermediate care service at that time, who have a length of stay within each of the following ranges:

0–6 days; 7–13 days; 14–20 days; 21–27 days; 28–34 days; 35–41 days; 42 days+.

Frequency of collection and submission

Data for this question should be collected daily and submitted weekly via the SDCS portal.

This is a mandatory field and must be completed to submit the template.

Timing of data collection

The data should provide a snapshot of people’s length of stay in intermediate care services. It should be collected on the same day each week to fit with your internal processes.

Additional guidance

This collection includes the total number of people within your service regardless of their length of stay or criteria to reside status. Therefore, delays of 1 day or longer should be captured.

Annex A: summary of question changes

Annex B: terminology used in the data collection

The information in this section should be considered in conjunction with the NHS Data Dictionary.

The definitions below are provided in the context of this data collection. We recognise that different localities may use different terminology and the list is intended to act as a guide. Links to further information embedded in the headings/definitions.

Adaptations to housing: adaptations made to people’s homes to enable them to return after a period of health and care in a different setting; for example, at the point of discharge from a hospital or community bed. Types of adaptations could include handrails for the stairs, grab rails for the bathroom or a wheelchair ramp.

Assessment of intermediate care needs: undertaken by a range of professionals, for example therapists, nursing staff or social workers, working in various locations. It aims to ensure that the type of intermediate care provided is appropriate for the person’s needs and circumstances. Assesses what specific support and rehabilitation would improve people’s ability to live independently, considering the person’s needs and wishes, so that they can be referred for the most appropriate support.

Better Care Fund (BCF): the BCF supports local systems to successfully deliver the integration of health and social care in a way that supports person-centred care, sustainability and better outcomes for people and carers.

Care Act assessment: how a local authority decides whether a person needs care and support in their day-to-day life. Because not all care needs are met by the State, the local authority uses an eligibility framework to decide which needs are eligible to be met by public care and support.

Care package: a combination of services that are brought together to meet a person’s specific care needs. Intermediate care packages are intended to be short term (up to 6 weeks) and focus on rehabilitation, reablement and recovery services. Assessments for longer-term care packages take place during intermediate care and particularly as this is coming to an end. They enable the development of a long-term care plan, which is usually delivered by social care following discharge from intermediate care services.

Care Transfer Hub: a focal point for co-ordinating discharge for people with new or increased needs who require post-discharge health and/or social care and support (that is, those on discharge Pathways 1, 2 and 3). All complex discharges into intermediate care will therefore be managed by the hub.

Continuing Healthcare: NHS Continuing Healthcare means a package of ongoing care that is arranged and funded solely by the NHS specifically for the relatively small number of individuals (with high levels of need) who are found to have a ‘primary health need’. Such care is provided to an individual aged 18 or over to meet health and associated social care needs that have arisen as a result of disability, accident or illness.

Criteria to reside (meeting requirement to remain in a service): clinical assessment has determined that the individual meets the criteria to reside in an intermediate care bed due to their rehabilitation, reablement and recovery needs. Clinicians are supported to determine the level of clinical need for intermediate care by the Pathway 2 clinical rehabilitation model (see below).

Discharge to assess (D2A):  a model where the assessment of longer-term or ongoing needs (if required) is completed only once a person has reached a point of recovery and stability. As discharge to assess is underpinned by simple principles rather than rigid criteria, there is no fixed delivery model for this.

Discharge pathways: discharge pathways define the support needs for people leaving hospital and care services:

• Pathway 0 – simple discharge to usual place of residence
• Pathway 1 – discharge to usual place of residence with health and social care support
• Pathway 2 – discharge co-ordinated by the Care Transfer Hub or local brokerage service to a community bedded setting with time-limited, short-term rehabilitation, reablement and recovery provision
• Pathway 3 – in rare circumstances for cases of high complex needs, discharge to a care home placement either for assessment or long-term care.

Discharge summary: a report prepared by clinicians at the conclusion of a person’s episode of care. It should summarise all the key information about the individual’s health status and the episode of care, the results of any tests and list medication. Discharge summaries are vital in the transfer of a person’s care between health and care services.

Equipment: items that are provided to help people remain independent in their home or to enable them to return to their home after a period of health and care in a different setting; for example, at the point of discharge from a community bed. Examples of equipment are walking frames, perching stools for use in the kitchen or shower, or toilet surround frames.

Intermediate care and intermediate care beds: intermediate care services provide short-term support to help people recover and increase their independence. This support is usually short-term bed-based care in community settings provided by a team of people to help people recover after a stay in hospital (step-down care) as well as avoid unnecessary acute hospital admissions (step-up care). For the purposes of the data collection, all community intermediate care beds are in scope regardless of whether they are step-up or step-down.

Jointly commissioned: refers to arrangements in which health and care bodies look to undertake planning and implementation collaboratively. This can involve the organisations pooling relevant budgets to collectively meet needs. The Better Care Fund (BCF) supports joint commissioning between health and care. For the purposes of this data collection, all community beds commissioned by the NHS, jointly or via the BCF are in scope.

Length of stay: the time a person remains within an intermediate care bed from the point of admission to discharge or transfer out of the service. If a person no longer meets the requirements to be in an intermediate care bed, their length of stay will include any additional time they spend within the service if their discharge is delayed. The intermediate care framework describes intermediate care as a short-term service usually lasting no longer than 6 weeks.

Meeting the requirement to remain in a service (criteria to reside): clinical assessment has determined that the individual meets the criteria to reside in an intermediate care bed due to their rehabilitation, reablement and recovery needs. Clinicians are supported to determine the level of clinical need for intermediate care by the Pathway 2 rehabilitation, reablement and recovery model (see below).

Non-specialist community bed: a community beds that is planned, arranged and commissioned locally. In contrast specialised services are planned and commissioned nationally and regionally by NHS England and are delivered by a small number of expert centres with small caseloads. They are clinically distinct and provide specialist services to support people with a range of rare and complex conditions.

No recourse to public funds (NRPF): a person who is granted permission to enter or stay in the UK may have a no recourse to public funds (NRPF) condition. Those who do not have permission to be in the UK and require it will have no recourse to public funds.

Pathway 2 clinical rehabilitation model: question 4 in the dataset summarises the Pathway 2 clinical rehabilitation model around low and high needs. The full model can be found on the FutureNHS platform. To request access to the Community Health Services workspace, please contact england.communityservices1@nhs.net

Rehabilitation, reablement and recovery: community rehabilitation interventions (including therapy-led reablement) are provided to the person on a short-term basis, to help them rehabilitate, reable and recover as much as possible from the event that led to their acute inpatient/virtual ward stay and maximise their independence. Services should be therapy-led with delivery through a multi-disciplinary, multi-agency workforce working in integrated ways.

Safeguarding concern: where concerns have been formally raised to protect people’s health, wellbeing and human rights from abuse or neglect.

Court of Protection: the legal body that oversees the operation of the Mental Capacity Act (2005).

Virtual ward (also known as hospital at home): allow patients to get the care they need at home safely and conveniently, rather than being in hospital.

Publication reference: PRN01281_i