Discharge to Assess (D2A) Service - Aberdeenshire

The Discharge to Assess (D2A) Service will support medically fit patients to leave hospital quickly and safely by providing short-term care, assessment, rehabilitation and enablement support in their own homes. The service will deliver intensive home-based support, seven days a week and focus on reducing long-term care needs and preventing hospital readmissions.

The Service Provider requirements: Deliver a high-quality service through a dedicated team working in partnership with the multidisciplinary team (MDT) to review and monitor agree individual referrals for patients who are medically fit for discharge but require a time-limited period of recovery, assessment, enablement and rehabilitation within their own home environment. Ensure agreed level of care and support will be put in place for an individual to enable an effective hospital discharge within the agreed timeframe with no delay.

Work closely with patients, families and staff within the Integrated Flow Hub based in Aberdeen Royal Infirmary and other members of the Discharge to Assess community-based teams to ensure that delivery of the commissioned service is provided in a rehab and enabling approach and tailored in line with assessed level of need. On discharge provide an intensive, targeted period of support and assessment at home for up to 21 days which will be delivered 7 days a week as assessed.

Normal working times will be between 7am – 10pm. Provide a care at home service for a targeted short period of time, undertaking but not limited to the following activities: ongoing assessment and adaptive support planning, personal care, medication administration, support with daily living activities including rehabilitation practice where relevant and signposting/supported referrals to other health and social care, statutory or community services as required.

Provide comprehensive and timely reports and communication on the progress of the persons outcomes following their discharge from hospital, and where appropriate, tailoring such service provision in a collaborative approach with the wider MDT. Work in collaboration with other stakeholders, including Allied Health Professionals, Health and Social Care Partnership staff, other providers and Third Sector organisations to ensure that the ongoing needs of supported individuals are met in an enabling approach which maximises the persons independence.

Continuously review the support delivered against the supported person’s identified goals and dynamically change care on a visit-by-visit basis as required. Work toward reducing the level of need over time through an enablement focussed approach to care delivery, preventing readmission to hospital and ultimately reducing the care requirement, and/or care home admission by enabling people to live at home, in their communities.

Considered with use of assistive technology when planning support and apply where appropriate to ensure that the least restrictive options of care and support are provided to meet personal outcomes. Liaise with Social Work teams and other Service Providers to support the arrangement of ongoing packages of care as assessed.

Ensure all staff have the appropriate qualifications and registration with the relevant professional bodies. Ensure all staff receive training in the following topics: adult support and protection, rehab and enablement, moving and handling, infection control, food hygiene, dementia, continence care, digital awareness and any other relevant topics specific to working with the Supported Person to achieve their outcomes.

Please provide a concise response (approximately 1 A4 page) detailing how your organisation will deliver the required service. Thank you