Reablement and Rehabiliation Services (Intermediate Care)
The Intermediate Care Service aims to:
- Provide support to help people maintain or regain lost independence.
- Prevent admissions into hospital.
- Reduce the amount of time that someone has to stay in hospital.
- Support early discharges from the hospital.
- Ensure that no one has to go into long-term residential care from hospital.
This support is usually for one to two weeks (but can be for up to six weeks), it is free of charge and involves input from more than one professional discipline to ensure that you have the help you need. If you need help for a longer period you will be given information and advice about how to arrange it or this will be arranged with you.
Intermediate Care services are only accessible by a health or social care professional who should make a Request for care and support to the Access to Adult Health and Social Care Team. Referrals are sent onto the most appropriate team which will carry out an assessment to ensure that it can adequately meet each persons needs, a plan of care will then be agreed including a date for commencement of the service. (Only after assessment by Intermediate Care assessors will a final decision be made regarding the appropriate service to meet needs).
The teams within Intermediate Care Services are:.
- Rapid Assessment and Intervention Team (RAIT): A multi-disciplinary team that provides nursing and therapeutic interventions, to rehabilitate people in their own homes. Individuals referred to RAIT should have identified achievable short-term goals within the service time-frame; from 1 day up to 6 weeks. The response times for the RAIT service are: Admission avoidance or crisis intervention - 2 hours; Therapy interventions to support discharge - within 72 hours; Nurse/OT cover in ED 9am to 7pm 7 days a week.
- Rapid Response Services: The Rapid Response Carer Service provides an over night service, working closely with Community Alarm, MKDoc and ambulance service to avert a crisis in the home and prevent the need for attendance or admission into hospital.
- Reablement and Hospital Discharge Team (RHDT): A team of Social Workers working closely with the RaHT and Milton Keynes Hospital to ensure individuals and their carers are offered social care support and assessment.
- Reablement at Home Team (RaHT): A team of experienced care staff who provide support with personal care tasks whilst promoting and supporting independence. Individuals referred to the RaHT should have identified achievable short term goals that can be met within the service time-frame (up to six weeks). The RaHT works closely with the Social Work Team to ensure that all individuals with a long-term care need are offered a Social Work assessment.
- Windsor Intermediate Care Unit (WICU): WICU is a nurse led unit, offering nursing and therapy support for people who require a period of rehabilitation to enable them to regain their physical functioning, independence and confidence to enable them to return home. There are 19 beds at WICU and it functions predominantly as an admission avoidance unit. WICU provides a service for people who:
- Have multiple reablement/rehabilitation needs
- Are medically stable
- Have outstanding health needs that require 24 hours qualified nursing
- Have identified short-term goals that can be delivered within a 3 week timescale with a maximum of 6 weeks
- Those who have a Milton Keynes GP or a GP within one of the CNWL-MK Service Level Agreements
- Those who have identified achievable short-term goals within a service time frame (maximum six weeks).
- Once goals are achieved, where appropriate, the service user will be discharged, or referred to another service.
Last Updated: 12 December 2017