Hospital Discharge Service

Provides a hospital discharge service (HDS) in Monmouthshire and is available throughout the county to residents over the age of 50, including -Those over 50 who may have some degree of confusion but do not require specialist care. -Those assessed as likely to benefit from short term and/or intensive support within their own homes. -Users at the point of hospital discharge, and for up to 6 weeks. The HDS provides practical and emotional support and encouragement, easing the individuals transition from hospital to home and on to independence. The team are alert to individual’s problems in the post-discharge period and will refer or signpost to other services, or for readmission as necessary. Support can be provided in a variety of ways and is tailored to the individual’s needs, with a focus on confidence building. This may include support with shopping, regaining independence in the home, signposting to other services and information and advice around benefits. The service is usually offered for a maximum of 6-8 weeks but is tailored to an individual and may be shorter or on rare occasions longer dependent on circumstances. The team work closely with the hospital discharge team and can receive referrals directly from hospital, social workers or from individuals and their families. Networking and promoting is also essential across both health and social care to ensure the appropriate people are aware of this service.