Integrated Rehabilitation Service (IRS)

The Integrated Rehabilitation Service helps people to remain as independent as possible within their own homes.

It supports people who have recently spent time in hospital, had an operation or who need rehabilitation support to prevent them being admitted to hospital when their health or mobility has deteriorated (as long as they are medically stable). The focus is on rehabilitation and promoting independence. 

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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IRS is managed by Surrey County Council’s Adult Social Care team. It works as part of CSH Surrey's multi-disciplinary health and social care teams, who together aim to provide a highly integrated service for patients. The IRS service incorporates a wide range of professions and skills from both CSH Surrey and Adult Social Care – including nurses, physiotherapists, rehabilitation assistants, occupational therapists, social care and reablement teams – meaning it can provide a comprehensive service covering all aspects of a person’s health and social needs.

Following assessment, the IRS team draws up an action plan for the patient to achieve a range of goals. This plan may include input from all or just a few members of the IRS team.

Following a referral, the patient will be placed on a waiting list. They will be contacted as soon as they reach the top of the list to make an appointment for an initial assessment. If a patient wishes to have a member of the family, a friend or an advocate present during the assessment, the IRS team will try to accommodate this and arrange the appointment accordingly.

A member of the IRS team will visit the patient in their home to assess them and their situation. Together they will identify any areas in which the patient is having difficulties and agree goals to achieve. Together they will agree a plan for how the IRS team can best assist the patient to become more independent and improve their quality of life.

Patients may receive input weekly, or will receive input based on their needs and goals. The IRS team member will arrange the appointments directly with the patient. The IRS team monitors and reviews each patient’s progress on an ongoing basis and adjust the plan as needed. The IRS team provides short term support, from a few days up to three months, depending on each patient’s needs.

The decision to discharge a patient from the IRS service will be made jointly with the patient based on the progress made and goals achieved.

If, at the end of their period with the IRS service, a patient needs ongoing intervention, the IRS team will assist with helping them access the appropriate service(s).

The IRS service works closely with larger multi-disciplinary health and social care teams who together aim to provide a highly integrated service for patients. Each community health and social care team can draw on the following expertise and services - so patient care is coordinated and managed between different services:

  • District Nurses and Community Staff Nurses
  • Community Matron
  • Mental Health Practitioner
  • End of life care (via CSH’s Community and Hospice Home Nursing Service, CHNNS)
  • Healthcare Assistants
  • Rapid Response Team to support unplanned care
  • Physiotherapists and Occupational Therapists to support rehabilitation (via the Domi Physio and IRS services)
  • Dietitians
  • Social Care Practitioner
  • Twilight Nursing (6.30-11.30pm).

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.