Hospital Disharge and Hospital Prevention

We are recommissioning a hospital prevention and discharge service designed to help individuals remain or resettle in their own homes after hospital admission. This is a preventative service that does not require CIW registration and will not provide formal care.

It aims to support people over the age of 50 living in Monmouthshire who lack suitable family or community support. The service will operate five to seven days a week and provide short-term interventions to enable safe hospital discharge or prevent admission.

It will work closely with social care teams, hospital discharge teams, and community healthcare professionals across Monmouthshire hospitals and other local hospitals, including Royal Gwent and The Grange. Referrals may also come from community healthcare teams managing individuals at risk of admission.

Support will focus on practical assistance and signposting. This includes helping individuals organize online shopping, access transport, and connect with community resources.

Once immediate needs are met, the service will encourage social engagement and financial stability by facilitating benefit checks, linking to third-sector organisations, and arranging services such as Meals on Wheels. Although primarily delivered face-to-face, the service will include follow-up phone calls and emails to monitor progress and make referrals where necessary.