A composite term used primarily in the UK, other English-speaking countries and the US, for supportive and rehabilitative healthcare given to a patient recuperating from an illness or intervention, who is regaining autonomy.
Four core terms to master Out-of-date terminology Correct terminology (NHS) Enhanced services Extended primary care services Community services Services delivered outside of hospital Shared care Services delivered by primary care in partnership with hospital Step-down care Community monitoring or Primary care-based management
The tool identifies patients who will require admission to the AT&R service after acute care, or who are at risk of needing step-down care. It calculates an overall score for each patient, based on their current actual (not premorbid) scores across six risk criteria: family support, mobility, cognition, continence, vision and malnutrition.
"However, emphasis will also be given to the promotion of independent living and intermediate step-down care by developing more short-stay accommodation, increased day-care provision and specialist day, night and respite care for elderly people with mental health problems."
Health services in Coventry and Warwickshire have already worked on schemes to provide step-down care for elderly people leaving hospital, linking with social services, district nursing teams and nursing homes.
The nursing/healthcare provided is expected to be provided by a team of qualified and unqualified staff that have specific skills and training in the delivery of step-up / step-down care to meet the needs of patients in the residential setting in collaboration with partner service providers, supporting optimal outcomes for patients.