Integrated Community Response Service (Hounslow)

Photograph of the integrated community response teamThe aim of the service is to prevent patients from being admitted to hospital if they don’t need to be and ensure that if patients do need to have a stay in hospital, that they are discharged as soon as possible to continue their care at home.

The team is made up of a GP, nurses, occupational therapists, physiotherapists, support staff, social workers, pharmacist and a handyman.

Staff within the team work for different organisations, such as the NHS and the London Borough of Hounslow, but work together to ensure that patients receive the right care from the right people at the right time.

Although the service works with patients of all ages, the majority of patients who use the service tend to be elderly as this particular patient group is more likely to have multiple health concerns, reduced mobility, or have frequent falls and require rehabilitation.

With the breadth of healthcare professionals within the team - patients benefit from receiving a comprehensive assessment and package of intervention which looks at all parts of their ability to stay at home, such as their health, social needs and mental health needs.

The team can be involved with a patient for up to 7 days and during this time plans will be made with the patient to ensure all ongoing needs are supported by working with and referring to other community services such as community nursing and therapies, GP, social services.

020 3771 6220 


Heart of Hounslow
92 Bath Road

  • Interim Clinical Services Manager - Sade Ajayi

All referrals to the service should be made using the HRCH referral form via the Single Point of Access service except London Ambulance Service who can telephone the service directly to make a verbal referral.

The service appreciates the inclusion of discharge summaries, clinic letters and functional reports as appropriate.

Any health or social care professional can refer patients to this service.

Once the patient is known to the service, the patient, relative or concerned other can re-refer a patient to the service. However the service does not accept self-referrals as the patients first referral to the service.

Patients must be:

  • Registered with NHS Hounslow GP
  • Over the age of 18 years including clients with a learning disability

Requires rapid assessment, intervention and / or rehabilitation within the patients chosen environment within two hours of receipt of referral following an immediate crisis and need for health intervention or breakdown of social care.

Patient will attend accident and emergency or be admitted to hospital within 24 hours of identification of need by referrer without immediate intervention.

Patient has a significant change in status following deterioration of health condition or acute episode requiring intensive multi-disciplinary assessment and intervention to manage risk at the point of discharge and to maximise recovery and rehabilitation potential prior to transfer into core community services.

The Integrated Community Response Team does not plan or facilitate discharge from hospital but will act on a consultative basis if there any blocks or gaps which are preventing early discharge.

Requires rapid assessment, intervention and/or rehabilitation in accident and emergency within two hours of receipt of referral following an immediate crisis and need for health intervention or breakdown of social care to prevent admission. Patient will be admitted to hospital without immediate intervention.

Patient must have two or more of the following:

  • 2 or more pathologies
  • 3 or more medications
  • Recent fall(s)
  • Recent hospital admission or increased visits to GP
  • Known to core community services

This form is to be completed for all patients who are being discharged back to their own homes or usual place of residence with a new or changed need for community support. 

Download North West London Needs-Based Assessment Form (Word document)

The North West London Needs-Based Assessment form can be used to refer patients registered with a GP in any of the North West London boroughs for community healthcare support delivered in their homes. For patients registered with a Hounslow GP this includes referrals to the integrated community response service

Completed forms should be sent to the Single Point of Access:

The service is open from 8am to 8pm every day, including weekends and bank holidays.