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.