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Intermediate care service
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About the service
The intermediate care service is provided to patients after leaving hospital or when they are at risk of being admitted to hospital.
The service is a ‘bridge’ between hospital and independent living and aims to stabilise and improve levels of independence and wellbeing to a point where support is no longer needed or the person can be offered other appropriate care/services.
The service aims to:
- Help people avoid going into hospital unnecessarily
- Assist people to be as independent as possible after a stay in hospital
- Prevent people from having to move permanently to a residential home unless they need to.
The intermediate care service is made up of:
Urgent community response service
Operating 24/7 as an alternative to hospital admission. The team undertakes intervention outside of service hours for district nursing, urology, palliative care, home enteral feeding and other specialist nurses. People are supported in their own home, nursing home etc, according to their need and level of dependency.
Neighbourhood rehabilitation service
The team provides rehabilitation to medically stable residents in their own home and residential care. The service provides specialist community therapy assessment and treatment to improve health and independence. In addition, the service offers rehabilitation to enable earlier discharge from hospital.
Why would someone choose the service?
- People are treated in their own home, instead of in hospital
- Service promotes wellbeing and independence – supporting people to effectively self-manage their condition whilst living in the community
- We promote faster recovery from illness – preventing unnecessary re-admission to hospital
Staff you may meet
- Nurses who choose to specialise in the mental health branch of nursing work with GPs, psychiatrists, psychologists, and others, to help care for patients. Increasingly, care is given in the community, with mental health nurses visiting patients and their families at home, in residential centres, in prisons or in specialist clinics or units.
- Nursing or healthcare assistants work in hospital or community settings under the guidance of a qualified healthcare professional. They help doctors, nurses and therapists give people the care and treatment they need.
- Occupational therapy is the assessment and treatment of physical and psychiatric conditions using specific, purposeful activity to prevent disability and promote independent function in all aspects of daily life.
- Physiotherapists help people to improve their range of movement in order to promote health and well being. This can help people to live more independently.
- Social workers help, support and protect people who are facing difficulties in their lives. They help people to take positive steps to overcome problems and improve their lives. This could involve assessing and reviewing a service user’s situation, building relationships with service users and their families and agreeing what practical support someone needs.
Why a professional should choose the service
- Greater numbers of frail elderly patients, increasing morbidities and more treatable illnesses and an increased public expectation of healthcare are contributing to pressure on health and social care services.
- Commissioning intermediate care services reduces the number of hospital admissions and allow early discharge as well as increasing the number of patients able to self-manage. This contributes towards financial savings and makes the service good value for money
Support offered
- Chronic disease and medicine management for housebound patients including intravenous therapy
- Terminal and palliative care enabling patients to die at home where it is their choice to do so
- Teaching self-care to enable patients to manage their own health needs
- Educating patients and carers to adapt to limitations imposed by related health problems
- Supporting and empowering patients to reach their full health potential through health promotion and education
- Preventing health complications associated with immobility disability or existing illness
- Wound management and tissue viability
- Collaborative care with other agencies
- Participating in the rehabilitation of patients following surgery, disability accident or illness event
- Supporting patients managing medical equipment at home
- Coordinating complex packages of care.
- To provide up to date information and advice to enable clients to make informed choices about the most appropriate services available to them
Outcomes
- To prevent hospital admission
- The patient is able to self-manage
- To allow early discharge from hospital
Referrals accepted from:
A & E, Consultants, GP staff, Hospital staff, Local authority staff, Other NHS services, Other Trust services
Referral criteria:
Patient must be registered with a Barnsley GP and have one of the following needs:
- Specialist assessment and intervention
- For urgent community response, require assessment within two hours to prevent a deterioration/hospital admission (this may include falls, end of life care, pain management, urgent catheter care etc)
- Intravenous therapy in the community setting
- Have an identified complex need that can be provided by a specialist care team
- Requires district nursing or other specialist community nursing service out of hours