December 2018: This chapter was revised throughout as a result of local review.

1. Introduction

Transitional care provides a period of recovery, rehabilitation, reablement and or assessment to an individual to determine immediate and longer term needs and or funding requirements.

It is designed to:

  • promote faster recovery from illness;
  • prevent unnecessary acute hospital admission;
  • prevent premature admission to long-term residential care;
  • support timely discharge from hospital;
  • maximise independent living.

This chapter provides information and guidance on:

  • Transitional care placements and referral process;
  • HART service – what they can do to support the individual at home and referral guidance.

There are four discharge pathways, from secondary care to community care: see Diagram 1: Transitional Care Pathways.

2. Transitional Care Placements

Assessment placements are available to patients who require a period of recovery or reassessment. These will be offered in community hospitals, and nursing and residential homes. Access to all placements will be through the Flow Management Team except Louth Hospital which will require a medic to medic referral.

3. HART Service

The Hospital Avoidance Response Team (HART) promotes independence and supports the individual through a health or social care crisis. The team provides support for up to 72 hours which enables an individual to remain at home or to return home more quickly.

The HART Service is available 24 hours a day 7 days a week. Click on the link to view contact details.

What HART can do:

  • if deemed appropriate, contact emergency services;
  • empty catheter bags;
  • tilt or turn a service user;
  • assist or prompt medication;
  • bathing or showering;
  • assistance with toileting;
  • assistance with dressing;
  • changing soiled linen;
  • support to get in and out of bed;
  • non-injury falls;
  • assist with mobility;
  • empower and enable;
  • food preparation;
  • help maintain a safe living environment;
  • ensure house is comfortable;
  • ensure daily essentials for living are available;
  • falls assessment;
  • provide access or signpost into support services.

What HART cannot do:

  • provide any medical intervention;
  • peg feeds;
  • assess blood sugar levels;
  • injections;
  • provide assistance with cannulas;
  • stoma care;
  • change catheter bag;
  • end of life care;
  • dress or redress open wounds or sores;
  • administer medication;
  • act on behalf of the care provider, if applicable;
  • assist with feeding;
  • general domestic chores.