The Hospital Social Care team and the Pathways Social Care team are two teams working closely together to support people who require adult social care support for discharge from places such as community hospitals and care homes, and those at home who have had reablement support following a hospital discharge.
Hospital Social Care team - what we do
The Hospital Social Care Team supports adults over 18. We:
- Work closely with health professionals and other organisations.
- Work with you to identify your strengths and connect you with support in your community.
- Provide direct help to you, your family, and carers during a crisis, helping you stay safe, build independence, and learn new skills.
- Assess your needs and help you decide what outcomes you want to achieve. Together, we create a support plan to meet your needs.
- Offer ongoing support and reviews, and update your support plan if your needs change.
- Work with other organisations, such as the Community Wellbeing Hub, Mind, Village Agents, and the Complex Health Needs Service, to provide the right support for you.
- Give advice and guidance on benefits, housing, employment, education, and training.
Community Pathways Social Care team - what we do
The Pathways Social Care team works with service users who have had reablement support following a hospital discharge and are identified to require long term support. We:
- Complete holistic care and support assessments, to establish your strengths, care and support needs, and their outcomes.
- Complete Carer's Assessments and initial reviews of commissioned support plans.
- Work collaboratively with you and your carer, and other professionals from health, housing, social care providers, and the Community Wellbeing Hub to help meet your identified outcomes.
Referrals into the team come via the Reablement and Hospital at Home teams. You can email them at ruh-tr.bathnesreferral@nhs.net.
How to get help
If you’re currently in hospital, please speak to ward staff and ask them to contact us.
Contact information
Our team is here to provide information, guidance, and practical help every step of the way. We believe in building on your strengths and working with you to find the best solutions for your wellbeing.
Urgent safety concerns
If you’re worried that someone is at immediate risk of harm, call 999.