What is intermediate care?

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.

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.