Adult and Community Services
A guide to intermediate care
What is intermediate care?
Intermediate care is a short period (normally no longer than 6 weeks) of intensive rehabilitation and treatment or intensive care. The aim is to make sure people who would otherwise be admitted to hospital or who would need to be in hospital for a long period are as independent as possible.
Intermediate care may also reduce or delay the need for long-term residential or nursing care.
How the government defines intermediate-care services
The Department of Health defines intermediate care as those services which meet all 5 of the following conditions.
- They must be targeted at people who would otherwise face unnecessarily long hospital stays or in-patient care or long-term residential care when this is not appropriate
- The services provided must be based on a thorough assessment. This should result in a structured individual-care plan agreed with each user and if relevant, their carer. The plan should involve active therapy, treatment or the opportunity for recovery. Intermediate care will always include a programme of active rehabilitation involving 1 or more of occupational therapy, physiotherapy, speech and language therapy
- The services should plan to make the person as independent as possible. This should usually mean that the person can stay living at home
- The services should be limited to a certain time - normally for no longer than 6 weeks and frequently as little as 1-2 weeks or less. If this time is extended, there should be a full reassessment, authorised by a senior clinician and including a review date within the 6-week period
- The services should work together within a single assessment framework. There should be 1 set of professional records and shared ways of working
How do I get an intermediate care service?
Contact the Intermediate Care Assessment Team. The team has many skills in managing care and nursing expertise.
Types of referral made to the Intermediate Care Assessment Team
Type of referral: Step up
When will the referral be made:
If it is identified that a hospital admission can be prevented by providing another intermediate care service.
Who will make the referral?:
- GPs
- Care manager working for Adult and Community Services
- Occupational therapists and physiotherapists
Type of referral: Step down
When will the referral be made:
If a hospital patient is medically stable enough to be discharged but will need intermediate care services within the community.
Who will make the referral?:
- Hospital discharge coordinators
- Nursing staff and medical team
Once we have received a referral, we will carry out our own assessment based on the information that we have received and gained from visiting the person. We will then make a decision as to which services, if any, are appropriate. A decision to provide social care services will be based on the Fair Access to Care eligibility framework.
How can members of the public make a referral to the Intermediate Care team?
If you feel that you or somebody that you care for would benefit from intermediate care services, you can discuss this with your doctor who can refer you to the team. Or you can contact the Adult Intake and Access Team.
Charging
Intermediate care is free to service users for a 6-week period. If, at the end of the 6-week period, you still need any social care, we will charge for this in the usual way. (See 'How much do I have to pay? - a guide to charges for home care').
What intermediate care services are available?
Intermediate care is generally provided in community-based settings such as specialist short-term stay residential homes, or your own home.
In Barking and Dagenham there are 3 specialist short-term stay residential homes (Kallar Lodge, Brockelbank Lodge and Hanbury Court). We also have an intermediate-care nursing team and a home support team.
Kallar Lodge is a local authority residential care home providing 8 intermediate-care beds with intensive physiotherapy for up to 6 weeks.
This facility provides services if you need rehabilitation and you can be cared for outside hospital but need out-of-hours social care. You work closely with the care staff and with physiotherapists and an occupational therapist to help regain your strength and independence before returning home.
Brockelbank Lodge is also a local authority residential care home. There are 12 'transitional beds' at this facility which provide care for up to 6 weeks.
Hanbury Court is a privately-run nursing care home with 8 transitional beds.
Grays Court site intermediate care centre|
A new 45-bed intermediate care centre has been built on the site of the old Grays Court residential care home. The centre uses the beds for rehabilitation and has strong links with the community and aims to provide therapeutic services.
Intermediate Home Support Team
This team is currently based at the Civic Centre and includes about 20 personal carers who work alongside the nursing staff in the Collaborative Care Team.
The team places the person at the centre of any decisions when they are discharged from hospital or if they are having a crisis in the community. This will allow people to stay in their own homes so they do not have to go back into residential or nursing homes.
The Collaborative Care Team
The Collaborative Care Team is based at St George's Hospital. It is paid for by the Primary Care Trust that offers mainly nursing and personal care over a 24 hour period, 7 days a week working closely with the 24 hour District Nursing Service.
This team provides intensive care within the intermediate-care residential settings and works closely with the Home Support team within the community.
Day-care opportunities
The Fanshawe and Galleon day care centres are run by Age Concern and provide intermediate-care services in the community.
Occupational therapy and physiotherapy
Therapy staff work closely with the Intermediate Care Assessment team to provide care and help you leave hospital early.
The consultant community geriatrician
The consultant community geriatrician aims to identify cases that should be referred to intermediate care at an early stage. They use a flexible approach in finding cases rather than waiting for cases to arise.
Accident and emergency discharge coordinators
These post are part of the accident and emergency multi-disciplinary teams. The coordinators work with accident and emergency and other agencies, coordinating care packages so patients who are assessed as medically fit but have complicated care needs can safely leave and return to the community.
They also encourage people to use community services in particular intermediate-care services and they provide expert advice, support and problem-solving for the Accident and Emergency Multi-Disciplinary Professional Team for patients who need social and nursing support when they leave hospital or care.
They work closely with the Intermediate Care Assessment team to make sure your care is continued when you leave.
A short guide to intermediate care 
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