Intervention Service - East Staffordshire Community

Intervention Service - East Staffordshire Community

Service model is split between two teams (Hospital discharge and Community Intervention)

A seamless rapid response and time limited service to manage the person safely within the community. Providing clinical and social intervention to maximise independence, prevent acute admission and the need for long term care and facilitate hospital discharge.

Who is the service for? 

The Community Intervention Service will support adults aged 18 or above who meet the following criteria:

• Are in short term clinical or social crisis, including palliative and learning disabilities cases
• Have consented to participation
• Have been assessed as able to be managed safely and effectively in the community
• Have social rehab potential
• Has a postcode (for social care needs) or a GP (for health needs) in South Staffordshire. (This will change over time)

What does the service offer?

  • Hospital Discharge Team including:
    • Planned hospital discharge responding to section 2s, section 5s, and pre-section 2s where applicable
    • Planned hospital discharge for elective procedures
    • Co-ordinating admissions to step down facilities
    • Supported end of life packages
    • Arranging social care support for discharge/brokerage
    • Supporting early discharge
    • Attending multi-disciplinary teams on wards
    • Safeguarding/ Deprivation of Liberty/ Safeguards and Applications
    • Assessing mental capacity
    • Admissions avoidance at A&E
    • Continuing Healthcare - A Continuing Healthcare Assessment will be commenced in an acute hospital to 'ensure that unnecessary stays on acute wards are avoided' as stated in the National Framework 2009. The assessment will be undertaken by acute hospital staff who have immediate access to the patient’s current medical and treatment notes and in collaboration with other Health and Social Care staff who are associated with the patient’s care.
  • Community Team including:
    • Avoiding admission to long term care for those who have potential to remain in the community
    • Crisis response (including palliative care and end of life crisis where rapid response is needed)
    • Intensive care management including weekly (or more frequent) reviews to endeavour to see that minimum support needed in the longer term and that the person remains as independent as possible
    • Implementing therapeutic interventions to endeavour to see that the person has access to the most appropriate intervention at the best time for them
    • Providing intensive rapid response in the least dependent environment to both medical and social needs
    • Managing capacity of available resources to endeavour to see a speedy and appropriate response e.g. step up and step down beds, specialist home care support
    • Responding to crisis caused by carer breakdown 
    • Implement Safeguarding/ Deprivation of Liberty/ Safeguards and Applications procedures as required
    • Providing specialist nursing interventions such as intravenous antibiotics, subcutaneous fluids, managing deep vein thrombosis, urinary tract infections, at home
    • Up to 12 weeks from date of referral to the community team
    • Contributing to appropriate assessments for step up, e.g. Continuing Healthcare
    • Assessing mental capacity
    • Where the person involved is already known to a Social Care key or named worker, this worker will coordinate the case management. 
    • Within the Integrated Community Intervention Service individuals who are identified as ‘end of life’ will be supported only if they have an urgent need for short term health or social care and does not include their ongoing palliative care. E.g. Intravenous antibiotics for a chest or urinary tract infection to avoid hospital admission or carer breakdown.
  • Community Reablement Services (LIS)
    • At home service to all identified assessed as eligible for needing social care support. 
    • Community led pulling in specialists as required and appropriate
    • Referred to by specialists in the community or hospital discharge teams
    • Safeguarding/ Deprivation of Liberty/ Safeguards and Applications
    • Up to 12 weeks after which long term support needs of the individual will be met by identified teams.
    • 7 day crisis intervention 
    • Delivering the plan for rehabilitation

Next Steps

What is the referral criteria for the service? Referrals will be taken from all partners including:

  • Central referral points
  • Integrated neighbourhood teams
  • Provider specialist teams
  • GPC groups
  • GP practices
  • Out of hours services
  • Voluntary sector (i.e. Marie Curie; Age UK; Starfish, Hospice at Home etc.)
  • Mental Health Trust
  • Prisons
  • Residential care homes
  • Palliative care services
  • Community pharmacists
  • Acute providers
  • Other statutory bodies
  • Self-referrals (long term conditions only)

Who may refer to this service? 

See above

Contact Us

Burton Hospital – Hospital Discharge Team

Anglesey House – Burton 

Telephone: numbers

  • BHFT – 01283 511511 (ask for Adult Social Work Team)
  • CIS Nurses – 07003996940
  • New referrals via Staffordshire Carers 0300 111 8000.

Fax numbers:

  • Hospital Team – 01283 593189
  • Anglesey House –  01283 233461

Service opening hours

  • Nursing staff work 7 days per week 7am to 7pm
  • All other team members currently work Mon to Friday 8.30am to 5pm (4.30pm on Friday)

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