Integrated Transfer of Care

The ITOC team has several functions:

Supporting discharges from the hospital setting:

We can carry out an assessment of all your needs and work with you to set short-term goals to enable a quicker discharge from hospital.

Discharge options are varied, a few are listed below:

• Home with no support required.
• Referral to voluntary agencies such as Age Concern for short term help at home.
• Home with a short term package of care and assessment period (where carers from Kirklees REACH service can come to help you in your home).
• Home with Reablement service otherwise known as support from Occupational Therapy and Physiotherapy, also called REACH.
• Home with a referral to other specialist services such as adult therapy team Neurological support, speech and language or dietician, or specialists in an area such a stroke.
• Transfer to an Intermediate Care Bed 
• Transfer to Recovery Hub 

We support with the relocation of patients from the hospital to the above settings.

Support to patients that have been transferred to the Recovery Hub:

The Recovery Hub at Moorlands Grange is a Kirklees service for people who no longer need hospital care but still need further assessments and recovery time before a safe discharge plan can be made.  

Frailty Assessments:

Following your discharge from A&E, we may arrange to visit you at home to assess your mobility, carry out a falls assessment, and identify any equipment to help you move around your home.

Accessing support from other services

If you need advice about benefits and other financial support, or require a social care package, the Locala ITOC team will be able to provide you with details of who to speak to e.g. Gateway to Care and Age UK.