HDD-OJEULT-56169- Assisted Discharge Low Level Community Support (Pembrokeshire)

The Pembrokeshire Integrated Assisted Discharge and Home Support Services aims to prevent unnecessary admission to hospital and facilitate early discharge from hospital and is a critical component of demand management from the perspective of the hospital and social care teams. The vision of the service is to utilise a range of third-sector intermediate care services, to provide a range of support, avoiding the need for conveyance to hospital and enabling people to stay safely in their own home. The service is not a regulated care service and therefore is designed to meet non personal care needs based on a person-centered assessment of needs. The staff supporting the service and conducting the assessment not only consider the health & care needs, but also look at the wider determinants of wellbeing, signposting to third-sector services, addressing issues such as loneliness and social isolation, financial hardship, and so on. This service does not operate in isolation or seek to duplicate other third sector services in operation but aims to leverage support and refer to other services where appropriate. It is expected that this service will be provided utilising a small number of substantive staff, supported by a pool of volunteers who will provide the majority of the service. This service will work collaboratively alongside the Welfare and Falls Rapid Response Service, Rapid Transport Service and Home Adaptations to Support Hospital Discharge Services in the Pembrokeshire area to support timely discharge from hospital when there is no medical need for a patient to remain.