Author: Jamal Mary

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Dacorum & Watford and Three Rivers - Intermediate care services

What is Intermediate Care?
Intermediate care is a service designed to enable patients to be discharged from hospital at the right time and prevent unnecessary hospital admission.
Intermediate care consists of a number of services where a patient is helped by one or more of the following: nurses, GPs, specialist hospital consultants, therapists, emergency care practioners Adult Care Services, and the voluntary sector to enable patients to be as independent as possible.
Intermediate care services can be provided at home, in nursing and residential care homes and inpatient hospital wards to patients over the age of 16.
Single Point of Contact 01234 292110
To access intermediate care services a single point of contact exists for all referrals by made professionals. This comprises of the following :
East of England Ambulance Service with qualified emergency care practioners and professionals / clinicians acting as co-ordinators to triage and sign post all appropriate patients to Intermediate care services. Patients who are not suitable for intermediate care will be referred to the appropriate service.
Responses to referrals are made within 1 hour or less
Able to give instant information regarding capacity within services
Acts as the communicator to all involved agencies when organising an urgent admission (capacity permitting)
Co-ordinates access to Dacorum & Watford and Three Rivers PCTs intermediate care services ensuring that the services function effectively and efficiently.
Acts as a resource for all agencies involved with intermediate care and has a good knowledge of alternative services when intermediate care is not considered appropriate.
Raises the profile of intermediate care.
Has established robust links with other professionals ensuring a seamless referral and assessment system.
The Single Point of Contact is supported by training and is organised on a rotational basis to empower and assist intermediate care staff in the admission process of patients.
The Intermediate Care Teams
To access the services patients must be registered with a Dacorum or Watford and Three Rivers GP. The Dacorum & Watford and Three Rivers PCTs provide the following intermediate care services:
Early Intervention Team
All patients referred to the service can be cared for either in their home or at one of our designated nursing and residential homes in partnership with Adult Care Services.
The Early Intervention Team will also provide support to the intermediate care bed based facilities for more complex cases depending on the needs of the patients.
Patients accepted for care by the Early Intervention Team include patients with a non life threatening condition, who would
alternatively be admitted to hospital and but will now remain under the care of their GP.
Early Intervention Team / Step Up
This service provides a 2 hour response from receipt of referral to the prevention and management of health and social crises. It provides short-term, intensive, frequent support treatment and care in collaboration with existing services. This is achieved by assessing and organising nursing therapy and social care for patients with sub acute conditions who would otherwise be admitted to hospital.
Early Intervention / Step Down
Supporting timely discharge from hospital for patients who no longer require an acute bed, but who would benefit from an enabling package of care. This integrated multidisciplinary team consists of nurses, emergency care practioners, therapists, social workers health and social care coordinators, support workers.
Home Based Rehabilitation Teams
All patients who are referred into this service are medically fit for rehabilitation but if the patient's mobility and function are compromised and where admission to the acute setting is not indicated e.g. : fallers, elderly, frail, post general or orthopaedic surgical, respiratory, trauma, musculoskeletal, rheumatology, appliance assessment, palliative care.
There are two Home Based teams who work in partnership with other services which cover the Dacorum & Watford and Three Rivers areas.
The teams provide rehabilitation (currently physiotherapy) for adults who are registered with a GP within the areas below . Occupational therapy will soon be available.
Patients are treated within their own place of residence i.e. own home or a temporary place of residence i.e. temporary residential setting.
Bed Based Services
A integrated team comprising of qualified nurses, hospital consultants and GPs support workers Adult Care Services staff and therapists provide rehabilitation in a designated intermediate care setting for up to a maximum of six weeks, which focuses upon the main principles of:
An integrated and focused health and social care service for people whose needs are otherwise difficult to meet.
Support and complement existing nursing therapy and care staff in meeting high levels of need.
Co-ordinated multidisciplinary approach to improve function in patients who are highly dependent.
Support to highly dependent patients on discharge from hospital.
Mary Jamal
Associated Director Of Intermediate Care
Dacorum & Watford and Three Rivers PCTs
21st September 2006

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Dacorum & Watford and Three Rivers—Intermediate care services

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Herts Health Informatics