Transitional care facility for elderly people in hospital awaiting a long term care bed: randomised controlled trial

Crotty and colleagues showed that transitional, or intermediate, care
facilities can be used to divert older people safely from hospital to a
care home setting [1]. Our RCT found similar findings [2] but we could not
exclude the possibility that such transitional care increases long term
institutionalisation over a longer period of follow-up (12 months,
compared to 4 months in Crotty and colleagues’ study). Young’s whole
system study in Leeds [3] showed that intermediate care services increased
hospitalisation. So, intermediate care sometimes can reduce
hospitalisation and sometimes does not. It is not guaranteed to lead to
outcomes that are equivalent to those of the services being replaced.

This inconsistency of the evidence base raises the question of whether
findings obtained in controlled research studies of services can be
generalised to other times and settings. If not, the fears raised by
Professors Ebrahim [4], Grimley Evans and Tallis [5] about the quality of
care for older people in intermediate care services cannot be put to rest
simply because some demonstration projects have shown acceptable findings.

Things might be different outside the setting of a controlled study, just
as they are between different trials. For example, and I cannot give much
detail while complaints are being investigated, I can report that in the
same city where I led our RCT of a “safe” residential intermediate care
service, it has been necessary to close one unit due to fears over patient
safety and it remains at this moment closed to community, step-up,
admissions on these grounds. It isn’t RCT evidence, but it is enough to
show that intermediate care can be unsafe.

We need high quality RCTs, such as that reported by Crotty and collegues,
to show what is possible but we also need to establish the conditions that
are necessary for success - those conditions that when not met lead to
ineffective or unsafe care. These are likely to include skill-mix, team
working practices, institutional policies and communication processes.

This is likely to require a wide range of descriptive research methods
such as systems analyses and case studies undertaken alongside controlled
studies. Once these conditions for success have been established, we need
a systematic quality assurance exercise to ensure that they are being met.

If we do not do this, then we may find ourselves so blinded by policy
pressure to keep older people out of hospital that we fail to do our jobs
as clinicians as we collude with the provision of sub-standard care.

1 Crotty M, Whitehead CH, Wundke R, et al. Transitional care facility
for elderly people in hospital awaiting a long term care bed: randomised
controlled trial. BMJ doi:10.1136/bmj.38638.441933.63 (published 2
November 2005)

2 Fleming S, Blake H, Gladman JRF, Hart E, Lymbery M, Dewey ME,
McCloughry H, Walker M, Miller P. A randomised controlled trial of a care
home rehabilitation service to reduce long term institutionalisation for
elderly people. Age Ageing 2004;33:384-390.

3 Young JB, Robinson M, Chell S, Sanderson D, Chaplin S, Burns E,
Fear J. A whole system study of intermediate care services for older
people Age Ageing 2005 34: 577-583.

4 Ebrahim S. New beginning for care for elderly people? Proposals for
intermediate care are reinventing workhouse wards. BMJ 2001;323:337-8.

5 Evans JG, Tallis RC. A new beginning for care for elderly people?
BMJ 2001;322:807-8.

Competing interests:
None declared