Integrated Rehabilitation Service (IRS)

The Integrated Rehabilitation Service helps people to remain as independent as possible within their own homes, taking into account their health and social circumstances.

The service supports people who have recently spent time in hospital or had an operation who need rehabilitation to return to independent at hoome. It also supports those who need rehabilitation support to prevent them being admitted to hospital when their health or mobility has deteriorated.

The IRS teams work as part of larger community teams that together provide holistic assessment, planning and care for people with a range of health and social care needs. 


"Everybody involved has been so helpful and full of ideas as to how life could be made easier for me...I have been in and out of many hospitals and have never before received so much help, so willingly given. Thank you all."

IRS patient

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The service provides short term support from a few days up to three months, depending on your needs.

After we receive a referral from your GP or other professional, a member of the team will visit you to assess your situation. They will identify the areas you are having difficulties with. They will agree a plan and goals with you to help you become more independent and improve your quality of life.

How often you receive input will be based on your needs and goals. The team will monitor and review your progress and adjust your care plan as needed. The decision to discharge a patient from the service will be made jointly with you based on the progress you have made and the goals you have achieved.

The IRS service has close working links to the community hub service, which employs a wide range of professionals from health and social care. Together they ensure all aspects of a person’s health and social care needs are addressed. The team will agree an action plan with you, which may include input from all or just a few members of the IRS or wider team. They will work together to help you become more independent.

Through the integrated community teams, patients benefit from:

  • Improved coordination, communication and support between services and settings, eg hospital and home
  • Single holistic assessments rather than being repeatedly assessed by different teams
  • Proactive and planned care to help avoid unnecessary hospital admissions
  • Greater information and access to support to help self-manage conditions
  • Rapid support if they require unplanned care.