NHS Rotherham CCG : Hospital and Community Admission Aftercare Service

The service will provide a support package to people over 60 years of age being discharged from The Rotherham Foundation Trust (including from the Urgent and Emergency Care Centre and Acute Medical Unit) or commissioned community beds. Clients are supported pre discharge to facilitate discharge to the home environment. A safety check will be carried out and the client settled. An assessment of need is carried out by the Care Coordinator and appropriate referrals and signposting made. The outcome of the assessment may lead to a person centered care plan being developed for a time limited packages being provided for up to thirty days aimed at improving physical function, social integration and maximising independence. Onward referrals will be made as appropriate and the service will work in collaboration with health and social care providers to ensure there is wrap around holistic support in place.

Aims and objectives of the service are:

To provide a flexible service model which may change in line with demand due to the impact of COViD 19 and recovery models.

To facilitate the early discharge of patients from hospital and community beds and reduce average length of stay.

Reduce the number of inappropriate admissions and readmissions to hospital or premature admission to long term residential and nursing care by supporting teams within the hospital and community.

To provide reablement and social care input to patients discharged from hospital.

Provide a high-quality service delivered by staff who are appropriately qualified and trained.

Deliver services that are flexible, person centered and provide continuity of care.

Provide short term non personal care packages designed to reduce dependence on long term care provision, focusing on the principles of reablement.

Support Wards, Integrated Discharge and Community Teams to follow up patients in the community.

Objectives:

Provide support with discharge planning and transfer of care from hospital and community beds to home environment.

To contribute to reducing risks by supporting discharge follow up.

To provide support to undertake activities of daily living using approaches that maximise independent activity and minimise the need for support.

To encourage and support maintenance of personal interests.

To promote economic wellbeing through advice and information on claiming benefits.

To promote independence by supporting and encouraging service users to access facilities and services in their community.

To act as an advocate for clients dealing with third parties on discharge from acute and community beds to ensure adequate provision of services and benefits.

To provide a flexible and responsive service which is sensitive to individual preferences and dislikes.

To promote a healthier lifestyle.

Additional information: The Contract will be for a term of two years with the option to extend for 24 months subject to mutual agreement between the successful Bidder and the Authority. The maximum term of Contract is consequently four years.

To access the procurement documentation, please go to www.nhssourcing.co.uk

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