The intermediate care service aims to support people who are well enough to leave hospital, but may need some extra support.

What is intermediate care?

Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care. When you are assessed for intermediate care, our staff will draw up a structured individual care plan which will be agreed with you. Intermediate care can provide a stepping stone to independent living.

Why might I need it?

You can be offered an intermediate care option if we think it might be unsafe for you to return home without support. You might require this service because of your current level of mobility or you might need more time to rehabilitate and gain confidence.

What kind of support can I receive?

If you are staying in hospital and require additional support after you leave, you will be assessed by our staff. We want to make sure you can stay safe and well. Support can include specialist equipment, an individual rehabilitation programme and assistance with personal care.

Who can refer me to intermediate care?

Our referrals usually come from hospital staff. They can also come from GPs, district nurses, The community therapy team, community palliative care team, and the Joint Emergency Team (JET). Some referrals come through from Local Authority social care, via reablement, if a person has a health and rehabilitation need causing their current requirement for care.

What are the different parts of intermediate care?

  1. Community Rehabilitation. This is for people who do not need to go into hospital, or who are now well enough to leave it, but require some rehabilitation to enable them to maximise their independence. This is a short-term service, for a maximum of four weeks. During this time, we will regularly review your progress so we can amend your care plan to meet your needs. We aim to support you to get back to your maximum level of
  2. Inpatient Rehabilitation Units. These are for people who need 24hour support and rehabilitation in a bedded unit, whose level of care and rehabilitation exceeds that which can be offered to support a safe discharge
  3. Interim Care Home Beds. These are for people who are not able to return home immediately. Local care homes can provide care for a short period of time. We aim to support you so you can return home as quickly and safely as
  4. End of Life Care. This is for people who have a life-limiting condition and choose to remain at home rather than stay in hospital.

Who works in the intermediate care team?

Depending on your care plan, you will meet several types of staff, some of whom are employed by the Intermediate Care Service, some we contract care to, and some we work alongside in the health service. A key person is your integrated care worker (ICW). They can provide personal care and rehabilitation. They work under the guidance of our team and take responsibility for your physical, emotional and social needs. This is for a defined period of time, appropriate for your needs. We also work with:

  • Therapy assistants;
  • Social workers;
  • Occupational therapists;
  • Physiotherapists;
  • Personal carers from local care agencies;
  • GPs;
  • District nurses, community nurses and specialist

What happens to me at the end of your service?

During the time we are providing support, we will work with you to decide on what care or support you might continue to need. We can help you, your family and carers, find this care or support. For example, you might choose a referral to social care if you will need longer-term care. You might also choose to have a referral to our community therapy team if you require a longer period of rehabilitation. Sometimes, for whatever reason, intermediate care does not meet all your health and care needs and you might need a hospital stay, hopefully for a short period of time.

Contact

Cambridge

0330 7260077 (Option 5)

East Cambs and Fenland

0330 7260077 (Option 3)

Huntingdon

0330 7260077 (Option 2)

Peterborough

0330 7260077 (Option 4)

Further information


The page was last updated on 18 November 2019 by Mark.Cole.

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Cambridgeshire and Peterborough NHS Foundation Trust
Elizabeth House, Fulbourn Hospital
Cambridge, CB21 5EF

T 01223 219400 (open 8:30am to 5pm)
F 01480 398501

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IP: 18.213.192.104