Clarifying patients’ needs and levels of services required

pam enderby Professor Pam Enderby MBE PhD is Professor of Community Rehabilitation at The University of Sheffield. She established the first AAC centre in the UK in 1980, and was awarded a Fellowship of the College of Speech Therapists in 1983. In 1993 Professor Enderby was honoured with an MBE for services to speech and language therapy.

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The myriad of services which are badged under various labels such as ‘community based rehabilitation services’, ‘enablement services’, ‘integrated care’ and ‘intermediate care’ have been established to address a wide range of health and social care needs of patients and are seen as significant and integral parts of modernised health and social care services aiming to maintain and restore the independence of older people who have a variety of health needs.

Increasing pressure on secondary care related to demographic changes has led to a year-on-year requirement to provide more services in the community in order to facilitate early discharge from hospital and avert avoidable admission. Frequently the identification of the requirement for active rehabilitation as compared to care and support are not clearly defined as the needs of the patient/older person are not made explicit. This makes it difficult to monitor the outcomes of services and to configure most appropriate skill mix to serve patient/client needs. This lack of clarity may be exacerbated by the development of more integrated services stimulated by the relatively new initiative of the Better Care Fund. ( ourwork/part-rel/transformation-fund/bcf-plan/)

Community services are generally required to intervene to assist with the consequences of conditions such as progressive neurological disease, a stroke, fall or chest infection.A synthesis of two studies of intermediate care in the UK allows comparison of changes over time relating to referral of patients to these services (1). The first study2 was carried out between 2005 and 2008; the second study (3) collected data between 2009 and 2011.

It is clear from this that there has been a change in the types of referrals to community-based intermediate care service between the two time points, with a higher percentage of patients in more recent years being inappropriately referred to active rehabilitation in intermediate care services and who did not require such intervention but required social support and care. Whilst this trend is clear the reasons for this are not. I would suggest that it is possible that this is associated with increasing time pressures necessitating the need to pass responsibility from the acute trust to a community trust without having the opportunity to consider the particular needs of the patient as they return home and the recognition that more detailed assessment of needs is required. Additionally, these studies confirmed that more recently, a higher proportion of patients with more complex conditions were being referred to community-based services needing a range of more active interventions from the broader interdisciplinary team.

Management of the patient/client will be dependent on the severity of the primary diagnosis in the context of other health restrictions, retained abilities, potential and social circumstances. As a result, it is difficult to determine the rehabilitation and care needs of the patient based on their medical diagnosis alone. Even cursory consideration of the range of patients who are being supported by community-based services would conclude that there is a requirement for a range of services which are flexible and respond to clients needs but also can be described in a meaningful manner to determine service strategy, staffing levels, skill mix and assist audit, benchmarking and contribute to planning.

Previous research has shown that community rehabilitation teams and intermediate care services are highly heterogeneous varying greatly in terms of their staffing models2.They are often based on historical models rather than the needs of patient groups.

Outcomes are difficult to compare and consequently their cost effectiveness is difficult to establish. To date there has been a lack of information available to community care practitioners to help plan and compare resource needs. Indeed many of the existing models or taxonomies detailed in community studies have been used to describe only one attribute of a community-based service, such as the purpose of the service.

Patients using intermediate care tend to be older (initial policies stipulated that they should be over 65 and have multiple morbidities). However their admission to intermediate care should indicate that they are medically stable and require some support to help them function more fully in their chosen living environment.This support may be in the form of rehabilitation to facilitate independence, or social care, to supplement skills, to maintain the status quo or to help with daily activities.

As a result of this difficulty, Enderby and Stevenson (1990) developed the 8 Levels of Care Tool (LOC), a taxonomy that identifies the needs of the patients, rather than the structure of the service.This was proposed to assist in the development of a range of integrated community-based services with the appropriate skill mix and formalising the approach adopted by many health and social care providers who determine the needs of an individual having completed an assessment of the situation. The classification system aimed to identify service objectives and was developed following a series of focus groups, forums and workshops with patients,carers and a broad range of community. More recently there has been a development of integrating a broader range of health and local authority services further stimulating the requirement for greater clarity in identifying the particular needs of a patient/client. Thus the 8 Levels of Care has been expanded to incorporate a further two: namely, ‘the patient/client does not need any health or social care support’ and ‘the patient/client needs palliative care’. These two were added following the more recent study (1) which indicated the increased number of individuals being referred to community-based services but who did not require them and the increasing number of patients receiving palliative care in their own homes and being supported by community services. See Table 1 below (click table to enlarge it).

pam enderby table

The synthesis of the two studies1 demonstrated that the LOC Tool does differentiate on the basis of dependency, length of stay, and service costs and was associated with outcomes as measured on the Therapy Outcome Measure. However it did not differentiate on the basis of staffing.


Using the ‘level of care’ assisted the audits detailed in the studies of intermediate and community-based services (1,2) bringing a greater understanding of the needs of clients and the range of services required. I would suggest that evaluation of the integrated services stimulated by the Better Care Fund may be held by using this approach.


  1. Ariss SM., Enderby PM., Smith T., Nancarrow S A., Bradburn MJ. Et al. 2015 Secondary Analysis and Literature Review Of Community Rehabilitation and Intermediate Care: an Information Resource Health Service Delivery Research 2015. 3 (1)
  2. Nancarrow S., Moran A., Enderby P. et al. (2010) The Relationship between workforce Flexibility and the Costs and Outcomes of Older Peoples Services. Report National Institute of Health Research, London.
  3. Nancarrow S A., Enderby P., Ariss SM., Smith T., Booth A., Et al. (2012) The Impact of Enhancing The Effectiveness of Interdisciplinary Working. Southampton. National Institute of Health Research. SDO
  4. Enderby P & Stevenson J (2000). What is Intermediate Care? Looking at Needs. Managing Community Care 8(6): 35-40.