The Milestone Intermediate Care Unit is a residential service provided by Waverley Care in partnership with the NHS, Health and Social Care and the Cyrenians Hospital In-reach Team.
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.
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.
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.
I came here so broken and uncertain, and the beginning of this journey started in room 9. I am leaving with so much hope and determination for the next chapter.
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.
There was a positive multidisciplinary approach to enable recovery and opportunities for people to engage with professionals that they otherwise would not have access to.