Health and social work services

Tender description

This service will offer individuals support through a holistic approach to their health and well-being. The service will support customers and carers to identify needs and work towards personal outcomes which enable independence and self-sufficiency. The service will signpost individuals towards community groups/resources and statutory services for any needs identified. The service will support timely discharge from hospital, reduce presentation to health and social care services and support individuals to avoid hospital readmission. Warwickshire County Council are seeking a single provider to provide a countywide service to: — actively work with social care and health professionals within both the acute hospital and discharge to assess pathway 1 and 2 settings to identify customers who would benefit from information, advice and practical support in order to be discharged from hospital in a timely way and reduce their likelihood of readmission, — complete guided assessments and support plans with patients and their carers to identify needs and outcomes, taking a strengths based approach, — co-produce support plans with patients and their carers alongside social care practitioners who are eligible for social care support, — identify community groups/services/resources that will assist patients in achieving their desired outcomes/needs, — signpost, support and refer patients and their carers to access an array of information and support from national and local organisations and local communities, — support patients and their carers to navigate the hospital discharge pathway, — be flexible in intervention duration dependent on assessed level of need, — complete a post service review with the customer to identify whether outcomes and actions agreed have been met, — identify from the post-service reviews, customers that have outstanding needs that could benefit from follow up support from community social prescribing schemes, — make onward referrals to community social prescribing/care navigation schemes as appropriate.