Network Data Lab - Topic 4: Intermediate Care

Project Description

This Health Foundation Network Data Lab (NDL) project investigated the effectiveness of Intermediate Care (IC) pathways for patients discharged from Liverpool University Hospitals NHS Foundation Trust. Intermediate care — including reablement, rehabilitation, and step-down care — plays a critical role in minimising hospital readmissions, but its reach and impact had historically been difficult to measure.

The study linked multiple NHS and social care datasets within the Cheshire & Merseyside Secure Data Environment to build a comprehensive picture of who receives IC, their clinical and demographic profile, and what happens to them in the 30 days following discharge.

Key areas of analysis:

• Cohort linkage: Matched inpatient discharge records (SUS-APCS) to Community Services Data Set (CSDS) and Adult Social Care (ASC) data to identify patients who entered IC within 7 days of discharge
• Patient profiling: Characterised IC and non-IC patients by age, gender, ethnicity, deprivation, frailty, and clinical segmentation using the Bridges to Health model
• Segment analysis: Identified the dominant health segments among IC recipients — Frailty/Dementia (44.9%), Long-Term Conditions (27.4%), and End of Life (18.8%)
• 30-day outcomes: Measured subsequent A&E attendances, hospital readmissions, GP contacts, and 111 calls to assess follow-on care demand after discharge

Key findings showed that IC recipients were markedly older (79.8% aged 70+) and more frail than non-IC patients, and that 26.7% were readmitted to hospital within 30 days — highlighting the clinical complexity of this population and the importance of well-coordinated post-discharge pathways.

Skills Used

• SQL / R (data linkage, descriptive analysis, cohort derivation)
• NHS Secure Data Environment (SDE / NDL)
• Multi-dataset linkage (SUS-APCS, CSDS, ASC, GP, SUS-ECDS, 111)
• Clinical segmentation (Bridges to Health methodology)
• Health outcomes analysis