Sub-acute care from an ‘insiders’ perspective

To the Editor

I am writing a response to the commentary by Alison et al. (2014), as a psychiatrist who worked in an Intermediate Care Centre (ICC) with 15 sub-acute beds for approximately 2 years.

From my point of view, there is little clarity about what constitutes ‘sub-acuity’ and who can safely be managed in the ICCs. This was a constant source of tension between referring clinicians and ICC management and was one of my major challenges to balance the wider service needs (particularly emergency service demand) while maintaining team morale and the model of care.

The operational guidelines of the ICCs explicitly state that it should be a ‘holistic nurse-led’ service. However, the clinical responsibility and accountability still lies with the psychiatrist and the clinical director. This creates confusion about clinical governance and has potential medico-legal implications. A recent evaluation of the ICC continues to reinforce the need to distance the ‘medical model’ from the ICC (Health Outcomes International, 2013). This pejorative perspective of the role of the psychiatrist explains much of the flaws with this model of care in South Australia and, in my view, is ideologically driven.

The length of stay (LOS) at the ICCs is intended to be between 5 and 14 days and has been capped at 21 days (ICCs Operational Guidelines) The capped LOS is highly problematic and fundamentally anti-recovery as it limits the sub-acute patient profile that could be managed in a more cost-effective and efficient manner. This also leads to premature discharge resulting in representation to the emergency services as observed in the ICC evaluation report.

It is my view that ICCs should adopt an integrative and ‘holistic biopsychosocial approach’ with clear and unambiguous medical leadership. The duration of stay should be defined by the needs of the patients and should not be capped at 21 days. The ICC model of care needs to be revisited and should be informed by our experiences. ICC caters to an entirely different patient profile in its present format and the limitations of this service need to be understood before presenting it as a substitute to inpatient beds.