Bedfordshire Transfer of Care Service

The service provides short term (up to a maximum of 6 weeks*) therapeutic rehabilitation to support a patient’s recovery and independence post hospital admission or to support the prevention of avoidable admissions into hospital.

It is the aim that within a couple of weeks of intervention, there will be progress made and independence regained. At this point, a discussion will be had and a discharge date from the service agreed. 

All rehabilitation plans will be individualised, patient-centred and goal orientated around the following Activities of Daily Living (ADL’s):

• Personal Care
• Self-confidence with medication administration
• Meal Preparation
• Transfers, Mobility, balance and muscle strengthening

*If it is identified at an early stage that rehabilitation is either inappropriate or limited, we will support a referral to a more appropriate service at the earliest convenience of the service. We will actively involve you and your next of kin (when requested) to signpost and support you towards other organisations or professionals. In the interim, you may be transferred to the Domiciliary Care Service to provide you with the required support of your care needs.
 

Referrals can be accepted from

• Hospital Discharge Teams 
• GPs
• Health Professionals
• Social Workers

The service supports the Discharge to Assess model in the Bedfordshire hospitals to support with the quicker identification and assessment of patients that are medically optimised and appropriate for pathway 1.

This is with the aim to provide a streamlined and rapid facilitation of discharge, ultimately supporting the prevention of hospital delays, deconditioning of the patient and the risk of acquiring Health Care Acquired Infections (HCAI’s). 

In some cases, patients may require support from the Local Authority with the provision of a Package of Care, which if identified the team will refer into with your consent. 

Bedfordshire Community Health Services (BCHS): Transfer of Care Team are working with two commissioned Domiciliary Care provider services to support patients with their care needs at home.  This is an essential service, and without it the rate of acute discharges and the volume of care delivered by BCHS could not occur. Patients will receive day to day support by the care provider whilst remaining under the care of BCHS. This interim service is provided for up to five weeks whilst the patients long-term care needs are assessed for and a package of care is sourced.

There are daily MDT meetings between BCHS and the care provider where the patient care needs are discussed. If it is identified that they would benefit from a long term package of care, a referral will be made with the patients consent to the Local Authority for an assessment. Depending on the outcome of the assessment, it will be identified if the patient may be required to self-fund the package of care.

Any patients identified as a self-funder will be given 1 week to source a permanent care package. Support to source a package of care is available at a cost from the Local Authority.
 

The service also supports the Urgent Care Response (UCR) Team in Bedfordshire by providing a responsive assessment of patients that are at risk of being hospitalised without the appropriate support being provided in the home environment.

It will either be a nurse/matron or therapist that responds to the urgent referral, depending on the primary need identified at triage.

Should it be identified that short term support or equipment would promote independence/regained confidence of the patient, then this can be provided from our equipment provider: Millbrook Healthcare.

Primary Care at Home North
Twinwoods, Milton Road, Clapham,
Bedford, MK41 6AT
 
Primary Care at Home Mid
Shefford Health Centre, Robert Lucas Drive, Shefford, SG17 5FS
 
Primary Care at Home South
Queensborough House, Friars Walk,
Dunstable, LU6 3JA