The aims of the team are the prevention of unnecessary hospital admissions, support for an earlier discharge from hospital and avoiding or delaying the need for long-term care. We do this by assessing the person's abilities, setting up a rehabilitation programme 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 rehabilitative support to help individuals recover from illness/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 each person may have a package of homecare provided and will be expected to follow an individual rehabilitation programme to work towards mutually agreed goals. The service is initially for a two week period and may be extended for up to a further 4 weeks in order to achieve these goals.
The individual can expect a holistic, team assessment to determine appropriateness of the ICT involvement. However, 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 first for their agreement to share information when necessary.
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.
Care Packages and Plans:
Care packages are flexible and designed to provide the best available support with professionals carrying out shared visits, as appropriate, with colleagues. Individuals will be given a copy of their support plan, which will be reviewed by a social worker as progress is achieved.
What happens on Discharge from ICT:
Afterwards, and with the consent of the person, further referrals will be made to other services for longer term support, with personal hygiene and nutritional needs. If required further therapy and nursing this can also be arranged.
The Intermediate Care Team (ICT) is provided free-of-charge. However, if an individual requires care from Adult Services after the period of Intermediate Care, there may be a charge for this, dependent on a financial assessment.