Transfer to Access (T2A) is a team of physiotherapists, occupational therapists, social care workers, nurses and GPs. The team manage a number of beds in care homes for patients who need additional support following discharge from hospital (step down) and people living at home who may need short-term or urgent support without going into hospital (step up).
All referrals are sent via the Integrated Discharge Team (IDT) Gateway on a Transfer of Care (TOC) form.
What happens after referral?
- The IDT team will screen the TOC forms and decide on a suitable pathway for the patient
- If the person can be supported at home, the Rapid Response/Home to Assess Team will put measures in place to support them
- If deemed suitable for a T2A bed then the TOC will be sent to the most suitable care home provider for consideration
- If the care home provider accepts the TOC then arrangements for transfer of the patient will be made accordingly
- If the care home provider feels they cannot meet the needs of a patient then the TOC is sent back to the IDT gateway and it will be re-sent to the next provider for consideration
What happens whilst the patient is in T2A?
- The patient’s mobility and function will be assessed and treated during their stay and discussed at the weekly MDT meeting and at SAFER Board rounds
- Weekly goals will be set and treatment plans adapted in order to support the patient’s progress
- Environmental visits and home visits will be carried out where necessary by the therapy team and appropriate equipment ordered from the loan store
- Cognitive Assessments are carried out and onward referrals are made to teams such as dementia liaison for support where needed
- Where possible, support will be put in place to enable the person to return home as soon as possible, with for example STAR (short term assessment and re-ablement team) or domiciliary care packages
- Where longer term placements are necessary, options will be discussed with the patient and their family to facilitate the move to a suitable discharge destination
Who is suitable for referral?
- Patients who are not managing well with their current package of care and require a period of assessment
- Patients who are at risk of hospital admission due to an emergency situation with their primary carer (not for carer respite)
- Patients requiring stabilisation and recovery from an episode of ill-health or hospitalisation, for targeted person-centred care, support and therapies to enable them to return home or to an alternative setting
Part of Single Point of Access and Referral to Community Services Integrated Gateway Team (SPARCS)