Discharge to Assess Short-term Rehabilitation / Reablement Beds

1. This notice is placed as a Prior Information Notice (PIN) to inform the market of BNSSG Integrated Care Boards (ICBs) (the Commissioner's), intention to recommission Discharge to Assess (D2A) Pathway 2, Rehabilitation bed base. The Commissioner would like to understand the level of provider interest in delivering these services. 2. BNSSG ICB (the Commissioner) is seeking to secure providers across the BNSSG geographical area with the capability and capacity to deliver short-term reablement/rehabilitation services, complex discharge planning and nursing and care support for service users identified as medically fit for discharge from the care of acute partners but still require rehabilitation in a bedded setting. BNNSG would also be interested to hear from Providers who could only provide the appropriate bedded environment (Minimum 12 beds /site) and care support where our community providers could deliver therapy, we would ask for facilities within the estate for the therapy team to be based on site. Appropriate estate would include single rooms of a size to provide therapy within and where available appropriate bariatric support. 3. These services will be overseen and supported by the commissioned system Community Provider (Sirona) who provides the majority of this service. D2A pathways are designed for people who are clinically optimized and no longer have criteria to reside in an acute hospital bed but may still require care services. The term 'medical optimization' is the point at which care, and assessment can be continued in a non-acute setting. This service is targeted at providing short-term care for those people who require rehabilitation or complex discharge planning in a community setting to promote independence and manage timely discharge for the person to return to their usual place of residence or an appropriate location to meet any on-going needs. The majority of service users supported through this contract will be expected to receive a rehabilitation service provided on the basis of a comprehensive assessment, resulting in a structured individual plan of care that involves active therapy, treatment, or opportunity for recovery. NHSE guidelines for Therapy provision for the frailty cohort are 3hrs face to face therapy per week in addition to a 24hr rehabilitation approach provided by the wider MDT. The Scope of the D2A Service Specification is: (see draft specification for full scope and eligibility) a. D2A P2 services in appropriately registered reablement centres, and nursing homes for adults according to the needs of the person. b. People who reside in BNSSG. c. Registered with a BNSSG GP. d. Specific outcomes that can be delivered by goal-based care planning within an agreed period of no more than 21 days working to the same 'HomeFirst' principals as acute partners where a person should be supported to return home as soon as the needs can be met by Pathway 1, or alternative discharge pathway. e. A medical condition that can be managed by a GP in primary care. f. The provider shall ensure that appropriate, trained staff resources are available to support the delivery of the P2 service in a bedded environment. These will include therapists to provide the full range of P2 rehabilitation services. 4. The contract is expected to commence on 1st April 2026 for a term of 2 years and an option to extend for a further 12 months up to 31st March 2029. 5. Focus on outcomes and flow to support system objectives are key and as such the utilisation of a Management Information System will be expected to support service development (see Draft Specification). 6. There is a growing need for the availability of bariatric services within this pathway and as such it will be expected that any offer of bariatric beds will be ringfenced for people within this service to ensure regular availability. Where this service is offered, the provider will be expected to provide all relevant equipment associated with this speciality. 7. TUPE will not apply 8. The system is constantly learning and responding to changes in demand and capacity. Any system evolution impacting this service will be supported through regular contractual meetings. 9. The overall financial envelope for the delivery of the contract(s) is expected to be £3.77m per annum, totalling £11.31m over the potential 3-year term. 10. Interested parties should register their interest formally via the Atamis portal (link provided below) no later than 12:00 Friday 30th June 2025. This exercise is being carried out by NHS South, Central and West Commissioning Support Unit (SCW) on behalf of the Commissioner.