Members of the Immediate care team
The immediate care service is range of multidisciplinary services, each providing care to ensure that individuals receive the right care at the right time and in the right place.
The two main aspects of these services are Intermediate Care and Hospital at Home and these teams work very closely together.
Our aim is to prevent unnecessary admission to acute hospital, promote faster recovery from illness and support timely discharge from hospital.
We have a number of specialist services you may be referred to by your GP or healthcare professional.
You can read more about these on the service page for each - see the individual boxes above.
Intermediate care can provide rehabilitation and advice that will enable you to improve your ability to carry out the daily tasks and activities that matter to you. Nurses, occupational therapists, physiotherapists, social care workers, support workers and therapy assistants work together with you to support your rehabilitation and recovery. The aim is to help you return home with a level of independence that ensures you will remain safe and well for as long as possible.
Hospital at home service
Hospital at Home is short term targeted intervention providing the level of acute care in an individual’s own home or care home that would be expected within a hospital.
How does the hospital at home service work?
Patients are referred to the Hospital at Home team by their GP or hospital medical staff to allow them to either be assessed and treated in their own environment or to continue their treatment prescribed whilst in hospital, in the comfort of their home environment. The service is led by a consultant.
Following referral, you are assessed at home by a nurse practitioner and/or advanced practitioner and/or a member of the medical team to identify your medical needs. They will carry out an initial assessment that includes checking bloods, pulse, blood pressure, temperature, and urine, as well as other investigations such as ECG, bladder scan or make arrangements for X-rays or other tests required from a hospital site.
Multidisciplinary input is provided as required from medical, nursing, therapy, pharmacy and specialist services. Support is also given to remain in your own environment by way of provision of equipment such as pressure relieving equipment, commode or walking aids as required.
The outcome of this is then discussed with the wider team and a plan to then manage your medical care in your own environment is implemented. The team co-ordinate your care plan and will also discuss and assess any social or additional needs you may have. This may include attending a medical outpatient clinic or, assessment and review centre if this is considered to be a necessary part of your treatment and will make referrals to other services as required, for example podiatry, dietetics, specialist clinics.
The specialist team meets daily to discuss treatment and ensure they are doing everything they can to help you stay healthy at home. Once your treatment is complete you will be discharged back to the care of your own GP with appropriate follow up plans if required.
This service helps you stay at within your own environment but this may not be possible for everyone. If our specialist team do not think you are well enough or able to function safely enough to receive your medical care in your own environment, you will be admitted to hospital.