The Home Team

The Home TeamThe aim of the Service:

Help with any support or guidance you may need following your stay in hospital or Intermediate Tier
Offering advice and guidance about community services and other sign posting
Maximising your independence at all times
Ensuring your journey home is a safe one

The Home Team is part of the Intermediate Tier and are based in a variety of settings to provide comprehensive assessment and case management support to individuals in hospital or in Intermediate Tier services.

The team focus on planned and timely admission and discharge working in partnership with NAViGO and Diana Princess of Wales Hospital, supporting the promotion of independence, re enablement, health and well-being for adults.

The service includes:

  • Combined assessment, including complex NHS continuing care assessment
  • Direct access to Recovery and Recuperation short stay placements
  • All individuals will have a case manager who will be responsible for their discharge out of hospital, through the recovery and recuperation service and handed over to the Intermediate tier provider services
  • Reinstating/restarting care packages
  • Provide and offer advice and guidance about other community services and signpost you to other services
  • Arranging equipment to enable safe discharge
  • Close liaison with community services

The Home Team is made up of multi disciplined practitioners including Nurse Practitioners, Social Worker and Admission and Discharge coordinators.

Who is the Home team service for?

Individuals over 18 years

If following an assessment you aren’t able to remain at home you may be offered a short term placement in the Beacon nursing and enablement unit or in one of the Care Plus Group Recovery and Recuperation beds in the community.

Throughout your stay in these beds you will be expected to participate in your individual care plan, to promote and maximise your independence with the ultimate goal with being discharge to your own home.

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