2. The hospital team

The hospital team

7) From hospital to home-Intermediate care

Intermediate care being provided to an eldery lady in her own home
Across Scotland the drive towards increased care at home and reduced length of stay in hospital has seen growth of specialist community services. These community services have different names in different areas but most will involve some rehabilitation and provision of a service either short or long term to ease the change from hospital to home.  These services are known collectively as Intermediate Care. Some services will be stroke specific and some will be general rehabilitation teams.

Such intermediate care teams will aim to provide the following.

  • Comprehensive assessment and structured plan for care which includes active therapy, treatment and recovery at home.
  • Extra help for people who would otherwise face unnecessary hospital admission or a long hospital stay as an in patient
  • Services to increase independence of the person to enable them to resume living at home safely.
  • Health and social care staff working jointly to meet the needs of the patient at home using shared assessment and processes to avoid repetition for the carer and patient.
  • To offer short term services (usually less than six weeks) to enable the person to learn or re learn skills needed to live at home.

Some of the names of these teams may differ depending on what services are available locally in your area. Rapid Response, Early Supported Discharge, Re-ablement, Community Outreach or Community Rehabilitation are names which may be used. In rural areas some of these services may be linked to your local Community Hospital or Day Hospital. Some services may be provided by Nurse Led Unit or Stroke Team.

If the person still has ongoing rehabilitation goals to achieve with graded support and further training at home, one of these intermediate care teams may be involved. The team is usually made up of several disciplines such as Physiotherapy, Occupational Therapy, Nursing or trained care workers. Goals which have been started in hospital can be continued at home. Some tasks which cannot be done in hospital such as outdoor mobility are best done from home. Intermediate care teams can work with carers to help you to be safe and confident in aspects of the carer role. Once this service finishes if the person still requires continued support and has had a needs assessment  a care package can be arranged to meet this ongoing need.

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