Mersey Care's Community Intermediate Care Services are multi-disciplinary teams of Health and Social Care professionals including Nurses, Occupational Therapists, Physiotherapists, Podiatrists, Social Workers and Support Workers.
The service aims to prevent people from being admitted to hospital, support people to return home after a recent hospital admission and enable people to live at home rather than in a care home, if they choose. Elements of the service also support people who are on the palliative pathway to move to the place they have chosen to die at the end of their life.
Multi-disciplinary teams support people and their carers when they are in transition between hospital and home, or have entered some kind of health and/or social care crisis at home.
The service delivers assessments, care and rehabilitation in a variety of settings such as the local acute hospital trusts, nursing and residential care settings and in the community in patients own homes across Liverpool.
Responding to a crisis:
The service responds rapidly to people in health and/or social care crisis in the community, in order to prevent avoidable admissions to hospital and make sure the right services are in place to support people at home. This may be provided by the multi-disciplinary team or may require involvement of other services such as district nurses, community matrons, and specialist teams.
Where a more supportive environment is needed, patients can be transferred to a temporary placement such as an intermediate care bed, or a transitional placement within a Local Authority care home until they can be supported to return home.
In Liverpool, this is available over 24 hours, 365 days per year. The team who support this service are known as the Emergency Response Team.
The rehab and reablement elements of the service aim to help people recover from recent loss of function due to an illness or fall, for example. It is delivered in patient's own homes.
Therapy services can also be provided to people who need a temporary placement in a nursing or residential care home. These are known as Reablement Hub beds and are delivered in partnership with the local authority and BUPA.
Care is provided to support people who are in a crisis at home or in A&E to prevent them being admitted to hospital or enable a quicker return home following a stay in hospital or an intermediate care bed. Carers within these services are able to combine care with a rehabilitative approach to support the wider team of health specialists looking after patients. Teams work closely with the local authority and other agencies to ensure patient's safety and wellbeing and make sure their needs are met in the long term.
Specialist nurses based in both hospital and community settings provide a variety of discharge planning services across Liverpool.
These services support the principles of intermediate care and work closely with their intermediate care team members to support on time safe discharge for patients with complex and continuing nursing needs. Staff support the assessment of patients entering or within the intermediate care system, ensuring their ongoing needs are met in the most appropriate environment until their return home.
The teams support discharge by providing complex nursing assessments to aid decision making such as admissions to nursing care homes, rapid transfers from hospital to the community to supporting palliative patients to die in their place of choice. They also provide funding for continuing health care and advice, support and continuing healthcare assessments to patients who are approaching the end of life.
Nurses will visit patients both in hospital and nursing homes to determine what levels of support they require to fund their ongoing physical and mental health care needs. Nurses and social workers within the team work closely with other health and social care professionals, and where appropriate family, friends and carers, to ensure assessments and information are accurate and timely to support the best outcomes for patients, including the allocation of funding and the best place of care.
The service delivers assessments, care and rehabilitation in a variety of settings such as the local acute hospital trusts (Royal Liverpool Hospital, Broadgreen Hospital), nursing and residential care settings and in the community in patients own homes across Liverpool and South Sefton.
Liverpool Out of Hospital Services: 0151 285 3715
Referrals for patients are accepted from health and social care professionals.
In Liverpool please contact Single Point of Contact on: 0151 285 4834
Patients in crisis in Liverpool should be referred to Emergency Response Team via the Single Point of Contact.
Liverpool Out of Hospital Services: 0151 285 3715
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