Services

Integrated Transfer of Care

Introduction

Locala's Integrated Transfer of Care (ITOC) team provides Therapy and Nursing support to D2A beds and recently commenced undertaking A&E and Frailty assessments of patients with the consolidation of the START service.

Locala's ITOC emerged from the Locala Community Discharge Team which was created in the wake of the COVID-19 pandemic to support rapid discharges from the acute. Since its inception, it has developed and expanded and has since been renamed the Integrated Transfer of Care.

Our Workforce

ITOC is an integrated health and social care team who works within the main feeder hospitals to support the discharge of patients on pathways 1-3, including Adult Social Care, nurses, therapists, assistant practitioners, specialist practitioners, and ACPs working in close partnership with the hospital discharge teams and wider Trust colleagues.

There is also an existing pilot to assess the need of providing a Hospice nurse as part of the ITOC to help support patients with discharges who are End of Life, Palliative or have long-term conditions who could be provided support through Kirkwood Hospice and its programs.

The ITOC is made up of multi-skilled health professionals and is based in Mid Yorkshire Hospital NHS Trust and Calderdale and Huddersfield NHS Foundation Trust.

The team's aim is to support and facilitate discharge following current NHS and Government guidance, working in partnership with Kirklees Social Care, the acute teams, and third sector, voluntary agencies.

Referrals

Referrals into the ITOC come direct from Acute and Local Authorities working within the acute. Working as an integrated triage with Local Authority colleagues, all referrals are assessed, and a decision is made as to what pathway is the most appropriate for the patient in relation to their care needs, with a focus on home first.

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