Integrated Community Assessment and Support Service (ICASS)



What is ICASS?

ICASS is the Integrated Community Assessment and Support Service. ICASS staff will, in agreement with the patient and those who currently provide support for the patient, assess their needs and provide what is necessary to help them recover.

ICASS is a service provided at home or care home and is made up of three main parts that work closely together, where necessary: -

  • Hospital at Home
  • Intermediate Care
  • Homecare Re-ablement

ICASS aims to improve care quality and outcomes for people. By enabling people to stay independent in their own home or in their community ICASS will improve the care and well-being for people in Fife.

Hospital at Home.

The role of the Hospital at Home team is to treat patients at home or care home by providing the same level of care that would be expected in hospital. This team is led by a medical consultant.


How does it work?

Most patients are referred to the Hospital at Home team by their GP although some may be referred following a short stay in hospital to allow them to continue their treatment in the comfort of their home.

Following referral, patients are assessed at home by a nurse, or doctor, or both, according to their needs.

They will carry out an initial assessment that can include checking bloods, pulse, blood pressure, temperature and urine, as well as other investigations such as ECG, or make arrangements for X-rays.

Once the assessment and tests are complete, the team co-ordinate your care plan which will also address any nursing and social needs. This may include attending a consultant out patient clinic or day hospital, if this is considered to be a necessary part of treatment.

The specialist team meets regularly to ensure they are doing everything they can to help individuals stay healthy in their own home.
This service aims to help indivudals to stay at home however this may not be possible for everyone. If our specialist team do not think an individual is well enough to receive care at home, they will be admitted to hospital.



Intermediate Care

Following treatment from the Hospital at Home team care plan may also involve some intermediate care services.

This is a multi-disciplinary team of nurses, occupational therapists, physiotherapists, clinical support workers and other community services who can provide a period of rehabilitation to aid recovery. This can be for a few days or a number of weeks depending on need.

Health and Social Work professionals can also refer people directly to the Intermediate Care Team.



Homecare Re-ablement

The Homecare Re-ablement service is an integral part of the ICASS model and will provide support and assistance to individuals that will enable them to regain independence wherever possible.

The team will provide a range of services from personal care, help with activities of daily living and other practical tasks for a time-limited period up to six weeks.

The approach will be to "do with" rather than to "do for" and staff will work with individuals to develop the confidence and practical skills to carry out these types of activities themselves.



For more information contact

NHS Fife, Switchboard 
Tel: 01592 643355
By Post: NHS Fife, Hayfield House Hayfield Road Kirkcaldy Fife KY2 5AH


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