Intermediate Care Service

If you have been in hospital, or had a trip or fall in your own home, you can now regain strength and independence with the help of the intermediate care team.

Nurses, Occupational Therapists, Physiotherapists, Social 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.

An assessment will be completed by a professional from the Intermediate Care team or a GP, who will decide with you if Intermediate Care is the right service for you and will make the request for the service.  You cannot access this service directly.

They will discuss any difficulties you are having and will plan with you a way of making it easier to manage things such as washing and dressing, making meals or moving about at home and outdoors. This can be for a few days or a number of weeks depending on your needs. Intermediate care will provide support and assistance that will enable you to regain independence wherever possible or seek the extra support you may need to stay in your own home.


How does intermediate care work?

You will be referred to intermediate care by a GP, hospital or other health and social care staff.

The team will work with you, your family and carers and agree outcomes to achieve an appropriate level of independence in everyday tasks and help you to manage your health issues by promoting general health and wellbeing.

The duration of the service will vary according to your individual need, but may range from days to weeks.  Visits will be reviewed and adjusted as required.  The team will work closely with other agencies including social work and voluntary organisations to ensure your care needs and personal outcomes are achieved.


Hospital at home service

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 should you be admitted to hospital. The team is led by a medical consultant.


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 continue their treatment in the comfort of their home.

Following referral you are assessed at home by a nurse practitioner 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 or make arrangements for X-rays. 

The outcome of this is then discussed with medical staff and a plan implemented.  The team co-ordinate your care plan and will also assess any nursing or social needs you may have.  This may include attending a medical outpatient clinic or day hospital, if this is considered to be a necessary part of your treatment and will make referrals to other services as required.

The specialist team meets daily to discuss treatment and ensure they are doing everything they can to help you stay healthy at home.

This service helps you stay at home but this may not be possible for everyone.  If our specialist team do not think you are well enough to receive care at home, you will be admitted to hospital.


Links

​Fife Health and Social Care Partnership - ICASS​