Table 1 Characteristics of the intermediate care model

Admission criteria

All AMC patients are eligible for admission to the transfer unit if they meet the following criteria:

- Patient is medically stable and curative treatment has been completed;

- Patient needs care that can be delivered by one nursing assistant;

- Patient is not eligible for other regular care services and cannot go home;

- Patient is insured;

- Patient does not need daily care and/or intensive physical therapy;

- Patient is not a drug addict, terminally ill or comatose, and does not have AIDS;

- Patient does not exhibit disturbing behaviour if he or she is a psychiatric or psychogeriatric patient.

- Patient has an official indication for discharge to a consecutive setting.

Transitional care

Three AMC liaison nurses control, plan and coordinate all transitions of AMC inpatients to the transfer unit systematised by agreed discharge procedures. The nursing home physician, occupational therapist, the liaison nurse and the head (an RN) assess whether an AMC patient will be admitted to the transfer ward.

Setting

20 transfer beds located in 10 rooms. The unit was established outside the AMC in a residential home in the South-eastern Amsterdam district. This institution accounts for 110 residential home places, 7 places for day care, 4 community health beds and 218 apartments for assisted living.

Staffing

Head of the transfer unit 1.0 FTE; nursing home physician 0.33 FTE, registered nurses 0.89 FTE; liaison nurses 0.5 FTE; occupational therapist 0.5 FTE; licensed practice nurses 11.61 FTE. Two physiotherapists with a practice in the residential care home are directly available for patients of the transfer unit. An AMC geriatric nursing specialist attends multidisciplinary meetings once a week.

Context

The AMC and Henriëtte Roland Holst House are located in the South-eastern Amsterdam district. This region accounts for approximately 85,000 residents of whom 7,000 (8%) are older than 65, and 61% belong to an ethnic minority. A number of institutions in the region provide care for the elderly: 1 AMC, 1 nursing home, 4 residential homes, 1 public home-care agency, 1 public health agency, 1 social care agency, 5 primary care centres and 1 institution for psychiatric care.

Commissioning

The local public insurer structurally finances the transfer unit. The annual budget is 758,205 euros. Transitional care is financed by the AMC budgets.