Milestone Intermediate Care Unit

The Milestone Intermediate Care Unit provides short-term residential care and support for vulnerable individuals recently discharged from the hospital who are homeless, at risk of homelessness, and living with or at risk of HIV/hepatitis C. Additionally, we offer support to individuals in the community, where admission can lead to early intervention, prevent hospitalization, or mitigate serious harm.

Service Overview

The Milestone Intermediate Care Unit operates a ten-bed registered residential care facility, offering round-the-clock care to individuals who meet the following criteria:

• Vulnerable or at high risk of homelessness
• Experiencing multiple complex needs including physical health conditions, mental health issues, and morbidity
• In need of initiation/stabilization on medication-assisted treatment for addiction
• Initiating or changing treatment for blood-borne viruses
• Requiring management of complex wound infections and trauma related to drug use

Referrals can come from both in-patient care (step-down pathway) and the community (step-up pathway). Our service provides a patient-centered and trauma-informed holistic package of care, facilitating recovery, addressing health needs, and offering social, welfare, financial, and housing support to enable a safe and appropriate discharge.

Referral Criteria

Healthcare professionals from the Royal Infirmary of Edinburgh, St John’s Hospital, or Western General Hospital can make referrals. Referrals are also accepted from community partners, including Access Place, Recovery services, hostel and supported accommodation staff, and social work.

Acute Step-Down Referral Pathway

Referrals for vulnerable, homeless patients, or those at high risk of homelessness with multiple complex needs, discharged from the hospital, should meet one or more of the following criteria:

• Confirmed/suspected COVID-19 disease requiring hospitalization and clinically stable for step-down care
• Ready for discharge but lacking access to safe or secure accommodation in the community
• Other complex and vulnerable individuals admitted to inpatient acute settings, such as those requiring ongoing antibiotic therapy, trauma-related injuries, social work input, or at high risk of drug-related death

Patients referred for the step-down pathway from the hospital undergo a comprehensive assessment by a member of the Cyrenians Hospital In-reach Team to determine their needs and the reason for the referral.

Community/Step-Up Referral Pathway

Referrals for vulnerable, homeless patients, or those at high risk of homelessness with multiple complex needs are accepted when:

• They have self-discharged from the hospital and are at high risk of readmission
• Their clinical needs cannot be met in the community following a clinical assessment of their level of need

This may include individuals requiring stabilization from drug/alcohol/mental health issues, assessment and treatment for significant physical and mental health conditions, monitoring of ongoing health issues, or support to access end-of-life care, existing health/social care/housing services, or additional support services.

All referrals and assessments are reviewed during weekly multidisciplinary team meetings to determine the need for admission. The team also regularly reviews the progress, recovery, and discharge planning of individuals currently in the service.

The multidisciplinary team comprises Waverley care managers and care team staff, Cyrenians manager, a clinician from the Regional Infectious Diseases Unit, and the community palliative care team.

Partners

We work closely with the NHS, Health and Social Care and other third sector organisations, particularly the Cyrenians Hospital Inreach Team, so we can ensure better health outcomes for the people we support.  The weekly multidisciplinary team meetings have enabled us to build strong relationships between the partners which help us to have open and honest conversations around some very challenging issues.

Partnership working is fundamental to our service delivery and the strength of these partnerships can be evidenced from feedback received during our inspection process.