Our Hospital Discharge Team

Helping your safe transition between hospital and home

If you have had a stay in hospital or re-enablement unit, such as the Beacon, our Hospital Discharge Team provide support and guidance to help you make a successful and safe move back into your own home.

The Hospital Discharge Team provide comprehensive assessment and case management support to individuals in hospital or in intermediate tier services, such as rehabilitation units.

The team work closely with NAViGO (Mental health services) and Diana Princess of Wales Hospital to support people and promote their independence, re-enablement, health and wellbeing.

The Hospital Discharge Team act as co-ordinators of the various care professionals and support agencies that need to be involved in the decision making, with you and your family, as to the best way to continue your care following discharge from hospital, through your recovery and ideally back into your own home.

What does the service include?

  • 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 Hospital Discharge Team is made up of multi-disciplined practitioners including Nurse Practitioners, Social Worker and Admission and Discharge coordinators. It is available to adults residing in North East Lincolnshire.

What if you are not able to move home immediately?

If, following your assessment you aren’t able to remain at home, you may be offered a short-term placement at the Beacon Rehabilitation and Enablement unit, or one of Care Plus Group’s Recovery and Recuperation beds in the community.

If this is the case, throughout your stay you will be participating in your individual care plan that we have designed to promote and maximise your independence with the ultimate goal of getting you back into your own home.

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