NHS Devon ICB- Plymouth Assisted Discharge Service

NHS Devon Integrated Care Board (ICB) wishes to commission a single provider to support individuals who may require some additional assistance on discharge from hospital (or another care setting), from an unregulated provider. This will be a flexible service that will offer a range of support in a person centred way. This could be a few hours support to help someone on their first day at home, assisting with shopping or providing a few visits and/or telephone support over a limited number of weeks.

The aim of the service is to provide support to patients at home once they become medically fit, so that they can regain independence at home and reduce the risk of deconditioning in hospital.

Key principles of the service:

• Work as a key member of the multi-disciplinary Care Transfer Hub to identify individuals who would be suitable for accessing the service.

• Act as single point of access and triage for individuals identified as appropriate for this service.

• Deliver a flexible, person centred, solution focussed service embedding the principals of a Discharge Personal Budget (the Discharge Person Budget enables a unique solution for each service user within the unit cost).

• Ensure service users are settled in safely at home after a spell in hospital.

• Support service users to become independent at home again.

• Improve service users' outcomes and wellbeing post discharge.

• Where support exists already, to refer/signpost and not duplicate.

• Develop and maintain knowledge of other services and networks and ensure service users are linked to information and encouraged to access support which may reduce anxiety and enhance ability to continue living independently in their home e.g. benefits, community meals, befriending, day centres.

• The support will seek to reduce the impact on POC delivered in the community by Domiciliary Care, in turn improving hospital flow and discharge (reduce reliance on statutory care).

• Reduce risk of readmission

• Reduce discharge delays.

• Reduce average length of stay in community beds.

• Improve 7 day working through supporting discharges at weekends.

• Support early flow by participating in early discharge planning before the day of discharge.

• Support discharge to usual place of residence in line with Better Care Fund (iBCF) Metrics.

The contract value is £395,735 per annum with a total contract value of £1,187,205 for the 3 year period, with an optional extension period of 2 additional years at the commissioners discretion.