We help people to remain as independent as possible within their own homes
We support people who have recently spent time in hospital, had an operation or who need rehabilitation support to prevent them being admitted to hospital when their health or mobility has deteriorated (as long as they are medically stable). Our focus is on rehabilitation and promoting independence.
We work as part of larger community teams that together provide holistic assessment, planning and care for people with a range of health and social care needs.
We work closely with larger multi-disciplinary health and social care teams who together aim to provide a highly integrated service for patients. Each team can draw on the following expertise and services - so patient care is coordinated and managed between different services:
- district nurses and community staff nurses
- end of life care
- physiotherapists and occupational therapists to support rehabilitation
- social workers
- 'hospital at home'
- the social work emergency service (SWES)
Through the integrated community teams, you will receive:
- improved coordination, communication and support between services and settings, such as hospital and home
- single holistic assessments rather than being repeatedly assessed by different teams
- proactive and planned care to help avoid unnecessary hospital admissions
- greater information and access to support to help self-manage conditions
- rapid support if you require unplanned care