Who we are

We are a service supporting complex discharges. We consist of multidisciplinary and multiskilled professionals, working to provide the best possible care for you when you are discharged from hospital.

Our multidisciplinary team includes representatives from the NHS – Kent Community Health Foundation Trust (KCHFT) and East Kent Hospitals University NHS Foundation Trust (EKHUFT) – as well as Kent County Council and the voluntary sector who we work in partnership with.

We understand going home after a stay in hospital may not be easy for everyone, which is why we are here. Our priority is to make sure you are in the right place at the right time for the best recovery possible. The best place for recovery is at home where you can continue to recover in a familiar environment.

All our referrals initially come via the hospital wards. Once we are told you may need our help to go home or that your home environment may not be suitable to meet your needs, we will get in touch with you before you are discharged from hospital. We will involve you and your family members in decision-making, if that is what you want.

After that we will work very closely with you and your family to support you and offer you suitable options, based on your needs.

Pathway one

This is a short-term assessment service for patients who have been transferred from hospital back to their home and need assessment for longer-term health and social care needs. This will be provided by KCHFT’s Acute Response Team (ART) or Kent County Council (KCC) with Hilton Nursing Partners or Kent Enablement at Home (KEaH).

How we can help

• We will provide carers to visit you in your own home and you will have a full assessment within 48 hours to plan for your longer-term care needs.
• Patients are prioritised based on clinical need.
• Visit times are 8 to 11.30am, 12noon to 2.30pm and 4 to 9pm. Specific time slots cannot be guaranteed.
• Your care package may change, depending on your needs.
• For ongoing care needs, you will be referred to social services and this may include a care needs assessment which can involve a financial assessment.
• If you have any queries once discharged, you can contact us.

Pathway two

If you require further rehabilitation or a period of recovery before returning home, you will be referred to one of our community hospitals or a care home setting to continue your recovery period. This can be anywhere in east Kent dependent on available beds.

Pathway three

This offers an assessment period in a temporary placement within a care home in east Kent. This is to help identify your long-term care needs and help you recover.

How we can help

• For this assessment period we will try to find a care home in your chosen east Kent area, however, due to capacity and demand the care home which can meet your needs may be anywhere in Kent.
• We aim to have your care needs assessed by a multi-disciplinary team, which includes a clinical nurse specialist for older people, social services and NHS continuing healthcare assessors.
• Your long-term care needs will be identified and agreed with you and your family.
• Our service is an NHS care and assessment service. For ongoing social care needs, you will be referred to social services where your financial situation may be assessed. Ongoing health needs may be assessed by NHS Continuing Healthcare.