Provision of a Supported Hospital Discharge Service

Description

The provision of a Supported Hospital Discharge Service which must be met by providers who wish to contract to provide the Service for Service Users resident in the Falkirk Council area. There are two main strands to the Service being specified. The first strand Service is a short term rehabilitation, reablement and assessment service for Service Users at risk of requiring long term residential/nursing care or to prevent hospitalisation. The second strand is to promptly facilitate the discharge from hospital of in-patients or those presenting for emergency care who have been assessed as clinically fit for discharge but who may, following a further home based assessment, be found to have a need for reablement or rehabilitation and a requirement for short term or longer term support in order to remain at home. In both cases the Provider will work closely with the Service User, family carers, Occupational Therapists, Physiotherapists, other health professionals and known community networks to facilitate a support plan that allows Service Users to remain within their homes. The Provider will participate in regular multi disciplinary meetings which will focus on the shared goals of maintaining the Service User within their home setting and of undertaking a robust assessment of any longer term supports which may be needed by the Service User.