Intermediate Care Team

The service provides nursing/therapy assessments and short term packages of care to patients who have either been discharged from hospital (under D2A-Discharge to Assess) or who need help to be able to remain at home after a fall, or where there is reduced mobility or struggling with activities of daily living due to an acute episode of illness.

This would include a holistic assessment and planning and implementing treatment, with the goal of enabling patients to maximise independence.

We work in conjunction with other teams to make sure that the patient is at the centre of the care and that both patient and carer participate in decision making.

Service details

The nurse or therapist will want to discuss in further detail your home set up and how you have been managing. They will also discuss your falls history and if you have had any previous therapy.

They will review your ability to move around the home, completing transfers from your chair, bed and toilet.

They will review your home environment to check safety and give advice on anything that could be done to improve the environment.

The nurse/ therapist will review all this information and if a piece of equipment is needed they will either provide it there and then, or order through our equipment service.

If exercises are recommended the therapist will go through these with you and advise when you should be doing them.

The nurse or therapist may also give you advice on other community services that may be available and appropriate to you.

If the nurse or therapist feels you need another appointment they will arrange a follow up, either to come and see you or by telephone.

They may have provided you with contact details for further services that you can access in your own time e.g. care and repair. They may also make further referrals to other community services e.g. social services.

Once the therapist feels that they have completed all that was discussed throughout your sessions they will discharge you.

Who is eligible for the service?

  • People registered with a Guildford or Waverly GP.
  • We accept referrals from healthcare professionals only.

How to access the service?

We accept referrals from both hospital and community based health professionals and from GPs based in Guildford and Waverley.

How can I tell you what I think of the Intermediate Care Team?

We very much value your feedback. A therapist may ask you to complete a therapy questionnaire or if you are having care support visits we also have a feedback form to capture your views.