February 2017
Single Point of Referral (SPoR): 0300 033 0333
Email: [email protected]
Website: www.cnwl.nhs.uk/cis
Community Independence Service – acute partner update
St Marys
Dear colleagues,
CIS Liaison (formerly In-reach) has been working closely with colleagues in the front-end of the
hospital which includes A&E and short-stay/observation wards, hospital therapy and discharge
teams to develop plans to change the role of CIS Liaison. These changes are in line with our new
service specification and included CIS Liaison changing to become an admission avoidance
service working in A&E and front-end areas; and ceasing to provide bridging care for downstream
wards.
Department
Emergency
Department (ED)
Unit
Accident & Emergency (A&E)
Acute Assessment Unit (AAU)
Clinical Decision Unit (CDU)
Ambulatory Emergency Care (AEC)
We had agreed with commissioners and partners to fully implement these changes on the 1 March,
however we have concerns about the service gap that this will create and impact on both hospitals
and social care. We have therefore agreed to pause the changes planned for the 1 March and will
be talking to commissioners about alternative arrangements to implement the new service whilst
not destabilising the current service which supports the overall discharge process.
Katherine Murray
Head of CIS
Dr Anita Logendra
CIS Clinical Lead
What does this mean in the short term?
CIS Liaison will continue to provide bridging care for downstream wards to support people to be
discharged home earlier.
Wherever our capacity allows CIS Liaison will continue to work closely with A&E departments and
front-end units to determine if people can be better supported at home or by other non-emergency
services rather than through hospital admission.
We will be continuing to work to improve the visibility of the service to our acute colleagues in A&E
and front-end areas. Throughout March you will see posters introducing our team and our
presence at board, ward rounds, teaching sessions and meetings. Uniforms are also on the
horizon so that our teams are instantly recognisable.
We will also be working with Partners on a much wider piece of work around hospital discharge to
improve and streamline processes in each borough.
What else does CIS offer?
CIS focuses on the delivery of unplanned care with an emphasis on providers working together to
manage patients outside of institutional care settings by coordinating care in their homes and the
community.
The service has two pathways which both involve a multidisciplinary team approach:

Rapid response – CIS Liaison is one part of this pathway. Rapid Response also provides
urgent help to support acute illness in the community when it is safe and appropriate to do
so (with input for up to 5 days). The team is made of up of nurses and therapists with CIS
GP and geriatrician support to the multi-disciplinary team. Please note that the rapid
response service is not intended to replace urgent district nursing who can respond within
24 hours

Rehabilitation and Reablement – both rehabilitation and reablement are offered for up to 6
weeks.
Rehabilitation provides physical and occupational therapies for housebound people to enable them
to achieve functional goals and improve their independence. Whereas previously rehabilitation
services operated with long waiting lists, we are moving to a 48 hour response rate to referrals.
Our current waiting times are around 2 weeks, varying slightly by borough.
Reablement services are provided in the home to help a person gain confidence and re-learn the
skills to carry out daily activities and practical tasks.
Who is the service for?

Those aged 18 years and over, including those in normal place of residence which includes
care and nursing homes requiring CIS service and over as follows:
o Healthcare: Patient must be entitled to receive NHS Care and usually resident in the
area covered by the three borough CCGs.
o Social Care: Service users must be resident within the relevant London Borough.
How do I refer?
Hospital discharge teams will be responsible for the completion of all discharge planning
assessments.
You can speak to CIS Liaison directly on their team number 07808 890 994 or the A&E Assessor
on 07730619878to discuss a patient or by contacting the Single Point of Referral for CIS on 0300
033 0333. CIS Liaison can assist with navigating the wider Community Independence Service as
required.
For referrals to rehabilitation services, the basis of referral to CIS therapists will be a trusted
assessment by the hospital therapist, ideally via the North West London Needs Based
Assessment Form. These will enable CIS staff to make clinically appropriate decisions; to
coordinate the completion of rehabilitation and reablement goals in the community. To refer please
send your assessment to [email protected] for urgent referrals requiring a 2 hour
response, you must also call the SPoR on 0300 033 0333 to discuss the patient with a clinician.
Reablement services are currently best accessed via the Hospital Social Work teams who will
process the referral and aim to initiate the care package within 24 hours. For Reablement referrals
requiring a quicker response please contact the CIS Liaison Team directly.

Tell us what you need
If you have any questions about the service email: [email protected]