Intermediate care (home and bed-based)

We provide a short stay rehabilitation service to patients and support them to return to their own home.

Overview of the service

The Intermediate Care Service is designed to improve a patient's mobility and independence. We support patients with daily living activities to enable them to return to their own homes, and provide further rehabilitation and/or social support as required. A therapist will assess the patient and establish their rehabilitation needs, before working with the patient to develop a personal rehabilitation plan. This could include support for mobility, stair practice, personal care and meal preparation.

We aim to give patients the opportunity to regain their previous level of independence within a short time frame.

Our rehabilitation beds are located within nursing or residential homes, which also provide therapy on weekdays.

Who can access this service?

To access this service patients must:

  • Be over 16 years of age
  • Be registered with a Sutton GP
  • Have a planned discharge destination (such as returning home, a care home, to a relative's home etc)
  • ​Be able to participate in a personal rehabilitation/care programme
  • Be motivated to regain their independence
  • Be able to achieve their goals for discharge back to their own home within one to six weeks
  • Require either supported discharge (which means the patient has short term rehabilitation needs and goals which cannot be met at home) or admission avoidance (which means the patient has short term rehabilitation and/or nursing needs)

This service is not suitable for:

  • Patients who are not medically stable
  • Patients who are unable to, or unmotivated to, engage with rehabilitation
  • Clients who require respite/social services step down support
  • Patients who require respite or convalescence care

Team members who may be involved in your care

  • Physiotherapists
  • Occupational Therapists
  • Rehabilitation Assistants

Supported discharge referrers are required to refer verbally and follow this with appropriate written information.

Is patient self-referral available?

No, patients need to be referred by a health or social care team.

Is transport provided?

This is a home-based service but transport is provided to prevent admission and on discharge if required.

Are home visits available?

A home assessment or visit will be conducted prior to discharge from a rehabilitation unit.

Contact us

For all enquiries from both patients and healthcare professionals, please contact:

The Royal Marsden Community Services
Carew House
Floor 2
Railway Approach
Wallington
SM6 0DX
Tel: 0208 661 3908
Email: rmh-tr.rmcsreferral@nhs.net
Fax: 0208 661 3910

Patients may be referred as supported discharges from hospital or admission avoidance from the community.