Worried about money?

There’s lots we can do to help. Find out what support is on offer.

Returning home from hospital

Telford Integrated Community Assessment Team (TICAT) 

Telford Integrated Community Assessment Team (TICAT) is made up of professionals from Health Services and Adult Social Care based at the Princess Royal Hospital (PRH).

If you experience an urgent change in your health that may require you to go into hospital or the hospital’s emergency department, TICAT may become involved to help with your discharge out of hospital.

A hospital professional (nurse, physiotherapist, occupational therapist) will complete an assessment with your agreement, to find out what support you might need to return home this is called a Fact Finding Assessment (FFA). The hospital professional is then responsible for referring your details to TICAT.

You have a right to request for a referral to TICAT from one of the hospital professionals. If you need more advice regarding medical treatment or concerns regarding communication you can approach the Patient Advice and Liaison Service (PALS) for assistance in requesting a referral to TICAT.

Once your referral has been received professionals from TICAT will work with you, your family and other professionals to have conversations on how we can support you to remain at home.

What is Enablement?

When you are ready to leave hospital and TICAT have received your referral from a hospital professional. We will then discuss with you what is needed to get you back home or where you normally live. It may be that you need further assessment, therapy, equipment and support to help you maintain or regain your independence.

Our team can offer you this in your own home.

We will work with you before return home to set your goals to aim towards, this will help you to remain as independent as you can be and for as long as possible.

Who can have these services?

You can receive these services if you:

  • are registered with a Telford and Wrekin, GP or pay your council tax to Telford & Wrekin Council
  • are willing and able to work with the team towards your agreed goals.

Will I have to pay?

During your recovery, rehabilitation and assessment period the service, which is an extension of your NHS care, is not liable to a payment from you. This may be for a maximum of 6 weeks but this could end sooner, even as soon as 48 hours.

You will be assessed throughout this period and your case worker will decide when you are no longer requiring this ‘short term’ support. At this point you will be assessed for any long term support you will need and will also have an assessment to decide the level of financial contribution you will have to make to this support.

The people who have been providing your care or the accommodation you have been in for this period will not necessarily remain the same.

The Aim

  • To work with you to keep you as independent and well as possible.
  • To provide you with some extra support to help you return home from hospital.
  • To work with you to help prevent you going back into hospital.
  • To prevent or reduce the need for a long term care package or residential care.

What are the benefits?

We will work with you to help you to remain living independently for as long as you can.

It is not about doing things for you, but helping you to gain the skills and confidence you need to manage independently or in a different way which will help you to remain at home.

A period of assessment and rehabilitation is offered before any decision is made on whether you require services provided through the Council on a long term basis.

How do I get this service?

From the moment you are admitted to hospital, the hospital professionals will be talking to you to understand what you think you need to return home and they will make a referral to TICAT if needed.

You have a right to request for a referral to TICAT from one of the hospital professionals.

Whilst hospital is a good place to be when you are first unwell and need hospital treatment, it is not the best place for you to be for too long. You have a real chance of picking up infections or losing the muscle strength and confidence to walk. In hospital you don’t move around as much as you would at home. Because of this we aim to get you back home, or where you normally live, as soon as the doctor says you are well enough to return home.

We will, wherever possible, arrange to support you in your own home. We know that you will make a better recovery in familiar surroundings.

Who arranges the help I need?

During your stay in hospital TICAT may be involved or the hospital professionals may use voluntary organisations to work with you to agree and arrange the programme for you to return back to your home.

If TICAT are involved, once you are back at home and throughout your ongoing assessment, carers may be visiting you to support and encourage you with the things you need to do at home.

When we visit you at home, we will plan with you further goals and things that you want to achieve as part of your ongoing assessment. We will also look at any equipment, assistive technology and support from informal carers, friends or family and any other support that you may already receive.

Visiting staff carry identification badges; always ask to see them.

What if I can’t go straight home?

We will discuss with you if you feel you are not able to return home when you leave hospital, you may be temporarily supported in alternative accommodation in the community. The alternative accommodation may be a bed within a residential or nursing care home or a community hospital. This is for a period of assessment, which may include a rehabilitation programme and will be an extension to your hospital stay but based in the community.

We will discuss with you the nearest available bed but please be aware this may not be in your local or preferred area. However, you cannot continue to occupy a hospital bed when you don’t need to be there.

If you are going to an alternative accommodation, please make sure you have appropriate clothing and footwear for the day time, you will be getting out of bed and getting dressed in your own clothes.

Our aim is to support you to return to your home as soon as possible. While you are working to return home, we will work with you so you can do the things you need to do at home and support you while you recover, you may receive physiotherapy, occupational therapy and/or nursing care.

When your outcomes have been achieved, or you are able to manage the things you need to do at home, your case worker (who will be allocated to you) will discuss your return home plans with you.

On the day of your discharge from our service, if you have been in alternative accommodation, you will be expected to vacate your room by 10am and, wherever possible, your case worker will discuss how you will get back home.

In the event you decline to vacate the bed or accommodation or you do not engage with discharge planning, we will issue you with a letter outlining the need to vacate and a charge will apply, if you are in a Nursing or Residential home.

Last updated: 23/05/2022 09:01

  1. Introduction
  2. Contact