The service provides multidisciplinary rehabilitation to patients in their own homes for a maximum of six weeks following acute/intermediate care admission or as early intervention to prevent the need for acute admission. The main aims of the service will be:

  • Prevention of unnecessary attendance at A&E or admission to an acute setting
  • Facilitation of timely and / or early discharge from hospital
  • Prevention of avoidable dependence on long term care

Maximising Independence 

Occupational therapy and Physiotherapy

This service provides rehabilitation for housebound patients, including in care homes, following injury, surgery, period of illness and/or deterioration. They support patients to get back to their optimum level of functioning over period of up to 6 weeks. Patients need to be able to engage with the therapy required and clear goals are set to help resident manage their condition, improve their level of functioning and carry out everyday activities independently.

Referral Criteria 

Urgent Referral (72hrs):

•When there is a risk of hospital admission that could be prevented with therapy.
•When there is a decline in function or mobility, including transfers, which is placing resident or care giver at risk.

Routine Referral (3 weeks):
•Patient can engage with therapy and follow clear rehabilitation goals which cannot be met by other specialist community services

Speech and Language Therapy

This service provides assessment, intervention and therapy for patients with swallowing and communication impairments living in the Wandsworth community, including in care homes. For patients who are housebound and non-housebound (including care home residents).

Urgent referral (72hrs):

•Recent chest infection in past 3 months likely to be aspiration related
•If there is significant discomfort on oral intake contributing to reduced appetite / fluid intake / weight loss
•Significant distressing coughing on oral intake
•Sudden onset swallow changes
•Rapidly deteriorating resident / EOL
•Total airway obstruction (choking)

Routine referral:
•Oral or pharyngeal phase swallow concerns
•Communication concerns

Service Operating Times:

Monday to Friday, 9am-5pm
Contact information: Wandsworth SPA details on there rather than our team mobile number.
Email clcht.wandsworthspa@nhs.net, SPA referrer line 0333 300 2350, SPA patient line 0333 300 0950
Response times: Urgent - 72 hours, Routine, 3 weeks
How to refer: Referrals should be sent via. Managed Referral to Single point of access Screener 07920861721 to discuss referrals. 

The service compromises a multidisciplinary team, including physiotherapists, occupational therapists, rehabilitation assistants/ support workers, medical consultant support through an MDT, speech and language therapists and administration staff.

The team works closely with the acute, intermediate and primary care services, social and voluntary agencies, to deliver collaborative health and social care and rehabilitation.

Primary care pathways

  • Multi-disciplinary: rehabilitation/enablement through a joint MDT programme
  • Uni-disciplinary: rehabilitation/enablement with single professional input as appropriate

Patient contact details

The service operates from Monday to Friday, 8.30am to 5.00pm.

GPs, acute trusts, social services, voluntary services and other healthcare services can refer in to this service.

Refereral information

Inclusion and exclusion criteria

The service provides an assessment, treatment and management for any individual over 18 who is registered with a Barnet GP. The service will also accept referrals for patients registered with a GP outside the borough whose commissioning body has an agreement to provide care with CLCH services in Barnet.

Inclusion

A client will be accepted by the service where there is clear evidence to support:

  • The potential of an individual to become more independent or through support from the service to achieve improved management of their health and support needs.
  • An individuals’ willingness to work with the service and level of motivation to sustain any intervention by its staff.
  • The patients’ ability to be managed safely within the home environment.

Exclusion

  • Patients with no rehabilitation potential including lack of cognitive ability to follow rehab goals and / or not motivated to participate in rehabilitation
  • Patients who are not medically cleared for discharge and are not likely to be in the near future.
  • Patients only requiring an escort home.
  • Patients with high dependency needs, including for example:
    • A decline in mobility necessitating assistance of two to stand / transfer
    • Clients who have toileting / continence needs which have not been met
    • Clients who are homeless
    • Clients who do not live in Barnet and with whom CLCH has no reciprocal financial arrangements

Sub services of intermediate care service

  • Falls service – service based in Finchley Memorial Hospital, providing medical/MDT assessment/treatment for fallers with attendance at eight week and 12 week educational/exercise based falls programme as appropriate.
  • Early stroke discharge – designated specialist MDT to facilitate earlier discharge for stroke patients. Intervention and support will be limited to six to eight weeks.
  • Stroke review – community hospital based medical/MDT OP clinic. Patients are offered six month or 12 month review after completion of ESD or IC stroke rehabilitation.
  • Barnet stroke support services - stroke navigation, review and communication support groups offered to stroke survivors residing in Barnet.

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