Welcome to Intermediate Care!
Central Manchester Intermediate Care is a short-stay bed-based and home-pathway service. It offers a multi-disciplinary rehabilitation service, enabling patients to gain as much independence as possible so they can return to, or remain at home. Our inpatient team offers 24hr nursing support and full MDT input to support patients during their time on the unit and is additionally able to offer therapy to patients within their own home following assessment and when safe to do so.
We are a 23 bedded unit, offering inpatient rehabilitation for up to 6 weeks. We take referrals for patients from across Manchester using the pathway 1, 2 and 3 referral criteria and work with Central Manchester Crisis Response team and our community colleagues to accept step-up patients from home to avoid unnecessary hospital admissions. We have access to the wider LCO services to support our patients including social workers, Speech and language therapists, podiatrists, and older age community mental health liaison.
Home pathway is a community based Intermediate Care service, where patients are assessed and prescribed therapy, to be carried out within their own home. The home pathway team are made up of therapists, rehabilitation assistants and nurses who are skilled in the provision of intermediate care in the home. They can step patients up into the bed base if there is an identified need, following the step-up process. Home pathway staff rotate into the bedded unit and vice versa.
Patient Flow coordinator:
The role of the patient flow coordinator is to facilitate appropriate and safe admissions into Delamere House and to liaise with the control room in relation to patient flow, admission and discharges, including delays. The patient flow coordinator will liaise with the referring acute trust to determine whether referrals are appropriate to come into intermediate and to identify the appropriate pathway for admission. Patient flow is involved in attending daily bed meetings and attending the weekly length of stay meetings to discuss patient flow throughout intermediate care.
Our admin team are involved in greeting patients and visitors on arrival into the unit. They support all aspects of administrative tasks within Intermediate care. They manage and create patient files, liaise with the acute trust and general practitioners within the community. They are tasked with arranging transport to enable our patients to attend appointments whilst at intermediate care and are involved in many other aspects of the general administration of intermediate care.
The senior team in ICT is comprised of the unit Matron, Registered Nurse Manager, Therapy Team Lead and Advanced Clinical Practitioner. Their role is to oversee the management of the unit and to ensure that the MDT can provide safe, effective, and evidence-based care, in line with MFT / LCO guidance and policy. The senior team support the MDT within ICT and liaise with the wider LCO to ensure that ICT provide harm-free care of a high standard and are effective in achieving favourable outcomes for our patients.
Physiotherapists in intermediate care work autonomously to develop a personalised rehabilitation plan for patients, setting realistic and achievable goals. They are responsible for assessing a patient’s initial moving and handling on arrival at the unit and ensuring all staff are made aware of the patient’s transfer and mobility capabilities and falls risk. They also review patients post fall and amend the patient’s moving and handling information as required.
Physiotherapists are involved in the discharge planning with patients and their families. They liaise with other members of the multidisciplinary team to ensure appropriate discharge planning. This often involves home visits with patients, ordering additional equipment as required and referral for minor or major adaptations.
Occupational therapists on the unit are involved in the assessment of patients ability to carry out their activities of daily living. The OT role is often heavily involved with patients and their families during admissions to intermediate care, in relation to identifying realistic goals to enable a safe and achievable discharge.
OT’s carry out personal care and kitchen assessments and are often required to order appropriate, sometimes specialised equipment for patients. They may also be involved in the completion of cognitive assessments, mental capacity assessments and best interest decisions in relation to discharge planning.
Our rehabilitation assistants are active on the unit in supporting patients to engage with their prescribed therapy plans. They help to facilitate daily rehabilitation classes and work closely with the therapy team in the assessment and ongoing management of patients who are admitted to Intermediate Care. The rehabilitation assistants are also actively involved with supporting our MDT in the provision of patient care on the unit
The unit is staffed by registered nurses 24hrs a day 365 days per year. Our nurses are involved in the daily clinical management of our patients. They administer medication, monitor clinical observations, provide wound care and risk assess our patients to identify their potential for deterioration. They are involved in monitoring and managing our patients daily and identifying signs of deterioration and / or clinical concern. They support our patient’s rehabilitation and help to engage patients in managing aspects of their own care independently e.g., medications / blood glucose monitoring. Our nursing team also regularly refer patients for onto our community teams for further care and are involved in supporting the process for patients who require relocation into 24hr care on discharge
Clinical Support Workers:
The clinical support workers provide essential daily care and support to our patients. They are heavily involved in the provision of personal care and continue the therapy recommendations set out by our therapy team. The clinical support workers assist patients with mealtimes and in developing their independence with washing/dressing and mobility activities. They also engage in activities such as group classes, puzzles, singing and games with our patients. This helps to stimulate the spirits of our patients and helps to raise morale.
Advanced Clinical Practitioner:
The ACP role within intermediate care is primarily a clinical role and involves supporting the admission, inpatient management, and discharge planning processes for our patients. The ACP works closely with the GPs on the unit to maintain and manage the clinical care of patients on the unit. To assess, diagnose, treat, and where appropriate, refer on, acute presentations. Avoiding unnecessary hospital admission and ensuring that patients are medically optimised and able to participate fully with their rehabilitation. The ACP is a senior member of the ICT team and is also involved in supporting the wider MDT, education, service improvement, leadership, and general day to day issues within the intermediate care unit.
The role of the Intermediate Care Doctor is to improve the care of patients in a holistic way, reduce their risk of hospital admission, improve their quality of life, and enable them to optimise their health and wellbeing. Providing medical management of patients and medical leadership of the team.
- Diagnosis, management/treatment of multiple conditions in a diverse and increasingly medically unstable and complex patient group with a predominance of Elderly care and Rehab medicine.
- Liaising with other healthcare professionals in both primary and secondary care to meet patients’ needs e.g., clinic referrals, advisory emails, ongoing management of clinical issues following hospital discharge
- Lead weekly MDTs
- Admissions using the Comprehensive Geriatric Assessment template
- Dealing with queries, bloods/investigations, acutely unwell patients
- Respect discussions
- Supervision and clinical education of medical students, pharmacists, nurses and ACPs.