Integrated Community Services

Who are we?

We are a joint Shropshire Community Health NHS Trust & Shropshire Council team, called Integrated Community Services (ICS).

The Integrated Community Services (ICS) team focus on “home first” for our patients to maximise their independence. Our team provide short-term support in your home when you have been discharged from hospital or to avoid you having an unnecessary admission to hospital. We will work with you to achieve your goals to allow you to live as independently as possible.

The team consists of nurses, occupational therapists, physio therapists, rehabilitation technicians, social workers, social work assistants, care coordinators, support workers and voluntary workers. We work as a multi-disciplinary team and work with our patients and their families to create solutions to allow them to live independently.

The people we see

Patients Leaving Hospital: Our team works closely with local hospitals to identify patients who are well enough to be discharged back to their own homes with appropriate support. Once our patients have returned home, they can expect a visit from a member of the team within 24 hours to establish whether the level of care is appropriate and work with the patient to set their goals to maximise independence.

Patients Needing Support to Avoid Unnecessary Hospital Stay: We work closely with all our partner organisations to ensure their patients who are unwell, but not requiring an acute hospital to treat their condition, are supported in own home.

Our patients are adults, who are generally older and who need a short period of support to continue to live independently, following a hospital stay or a period of illness. However, the service is not designed to support people who have a primary need relating to mental health, substance misuse, learning disability or end of life care. Intensive or specialist nursing treatment is currently carried out by community nurses in the Inter-Disciplinary Teams.

All referrals to ICS are made through Health or Social Care professionals, self-referrals are not currently supported.

Existing patients

As a patient of ICS, when you get home, our care coordinators will have set up an initial support package. You will be visited by one of our health or social care professionals within 24 hours of arriving home to work with you to set your goals to maximise your independence.

You will be given a folder with the important contact details and your support plan with your goals. Please refer to the folder if you need to contact the team.

ICS works in localities throughout Shropshire (Central, North West, North East, South West, South East); your ICS worker will let you know which base they are operating from, and which contact numbers to use.

 

Special Educational Needs and Disability (SEND) and our "Local Offer"

What is the Local Offer?

The local offer provides information for children and young people with special educational needs (SEND) and their parents or carers in a single place. You can find out more about information about this on our SEND reforms and Local Offers page.

Service Description

The Integrated Community Services Team (ICS) provides short-term focussed reablement in the patient’s home with the aim of preventing admission, supporting early discharge from hospital and regaining independence.

Who is in charge?

We have an Integrated Community Services Manager, who is supported by three Team Leaders (responsible for running the North, South, and Central Teams, respectively).

Is there any information about ICS?

An information leaflet is available for patients and their carers/family. This is given to all patients, but can also be downloaded from this page on the right.

Who can use our service? Age? Disability?

Our patients are adults (18+), who are generally older and who need a short period of support to continue to live independently, following a hospital stay or a period of illness. However, the service is not designed to support people who have a primary need relating to mental health, substance misuse, learning disability or end of life care. Intensive or specialist nursing treatment is currently carried out by community nurses in the Inter-Disciplinary Teams.

All referrals to ICS are made through Health or Social Care professionals, self-referrals are not currently supported.

When and where is our service available?

Integrated Care Service teams are based across Shropshire in the Shrewsbury (Central), North East, North West, South East and South West and any team can provide support to avoid unneccessary admittance into hospital or supported discharge from hospital back to a patients’ "home".

Services are delivered in the patient’s own home or usual place of residence and is available 7 days a week, 52 weeks per year.

How to find out about the service

Patient satisfaction surveys are conducted on a regular basis. We have a translation service available. Advice and support with communication is available from specialist services e.g. Learning disability nurses, speech and language specialist, if required. Care and treatment plans are agreed jointly with the patient/carer.

How can families contact the service?

Referrals to the Integrated Community Services are through Hospital Ward staff around the local health economy or through a health or social care professional or general practitioner (GP), they will contact the service via the Single Point of Referral.

Once referred to the service, the team will give you their contact details for you to liaise with them directly.

For external agencies: is the service free or charged?

Free as part of NHS

Is the service accredited? If so, by whom?

Care Quality Commission

How can families complain if they are not happy with the service?

All complaints are handled by our Patient Advice and Liaison Service (PALS) and Complaints teams.

 

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