Intermediate Care Team (ICT) Horsham

The Intermediate Care Team (ICT) is a multi-disciplinary rehabilitation team including:

  • Physiotherapists
  • Occupational Therapists
  • Rehabilitation Technician
  • Rehabilitation Assistants
  • Administration Staff

The aims of the team are the prevention of unnecessary hospital admissions, facilitating earlier discharge from hospital, avoiding or delaying the need for long-term care, and promoting faster recovery from illness, and maximising independent living supporting people to remain at home or a place of their choice.

We do this by assessing the person's abilities, agreeing goals with the individual, setting up a rehabilitation program and monitoring the progress made. Individuals must consent to the referral and be medically stable before they will be taken on by the team.

We provide short term rehabilitative support to help individuals recover from illness or injury. This is achieved by agreeing goals with people and by helping them to become as independent as possible in their own homes. Subject to assessment by the social services assistant care manager, the person may have a package of homecare provided. Patients will be expected to follow an individual rehabilitation program to work towards mutually agreed goals. The service is initially for a 2 week period and may be extended for up to a further 4 weeks in order to achieve their goals.

We work closely with primary and secondary care, voluntary and private organisations, and other health professionals as appropriate. These include District Nurses, Community Matrons, Falls & Fracture Prevention Service, Community Neurological Rehabilitation Team, Palliative Care Teams, and Social Service Assistant Care Manager Specialist

Our service is for patients in the Horsham area. Patients must be registered with one the following GP surgeries: Courtyard, Holbrook, Orchard, Park, Riverside, Village, Rudgwick and Cowfold.

Coverage

Cowfold, Horsham, Rudgwick

How To Access

Referrals can be made by health and social care professionals including: GP’s, community nurses and matrons, social workers, hospital consultants, nurses, paramedics, emergency care practitioners, and care scheme managers. These referrals must go via One Call, a single point of access which operates 24 hours a day, 7 days a week, on 01293 228 311.

Patients and family can refer themselves if, when triaged by a One Call clinician, the referral is deemed to be appropriate. The patient must have consented to the referral and must be registered with a GP in Horsham, Village (Southwater), Rudgwick or Cowfold.

Criteria:

Patients must:

  • Be registered with a GP in Horsham – Village (Southwater), Rudgwick or Cowfold
  • Be medically stable
  • Be able to consent to participation in and would benefit from a rehabilitation program
  • Have rehabilitation potential
  • Be unable to attend for outpatient treatment

Patients are referred for rehabilitation following:

  • An acute hospital admission for illness or surgery, and require post discharge support
  • An alteration of complex medication
  • An acute worsening in their health such as infection
  • An illness or a disability which has recently changed
  • A deterioration of health reducing patients ability to carry out day to day personal & social care activities

Contact Details

Intermediate Care Team (ICT) Horsham
Rose Wing
Hurst Road
Horsham Hospital
RH12 2DR
Tel: 01403 227000 ext 7538/30
Fax: 01903 276984
Out of hours contact: One Call 01293 228311

Opening Hours

8.30am to 4.30pm Monday to Friday

How to find us

We are located in The Rose Wing, Horsham Hospital. We don’t see patients here as we are a Community service and only visit people in their own homes.

More information

Assessment:

The individual can expect a holistic, multi-disciplinary team initial assessment to determine need for ICT involvement. Following this, further specialist assessment may need to be completed by the professional members of our team. Confidentiality is a priority and the person will be asked for their agreement to share information.

Care Co-ordination & Care Planning:

Once the assessment has been completed, a care plan will be developed to meet the person's particular needs and may involve any of the team members. A key worker will be allocated to co-ordinate the person’s care. The goals will be agreed between the person and team, and reviewed.

Care Packages:

Social Services assess for care packages following request by ICT. Care packages are tailored to patient’s needs. These will be reviewed as progress is made or changes in need identified.

What happens on Discharge from ICT:

Discharge from ICT occurs when agreed goals of care and treatment plan are reached. Afterwards, and with the consent of the patient, further referrals will be made to other services, if required. GP and referrer would be notified of patient’s discharge.