Support Leaving Hospital (Joint Care Pathway)

Leaving hospital

In West Berkshire, Berkshire NHS Intermediate Care Team and West Berkshire Council Adult Social Care work together to support people being discharged from hospital through our Joint Care Pathway (JCP) Team. This provides intermediate care or reablement and is a goal focused, short-term intervention to help adults regain their independence following an illness or operation.

Are you able to go home and do you have reablement goals?

Whilst you are in hospital, hospital staff will assess your health and decide if you need further help to recover by setting reablement goals. If you can go home and have reablement goals, you will be discharged on Pathway 1 with reablement.

This is a goal-focused intervention that involves intensive, time-limited assessment and therapeutic work over a short period of time, normally 1-2 weeks. The care may be through an occupational therapist, physiotherapist, therapy assistant or a reablement officer and delivered by Community Health or West Berkshire Council's Reablement Team.

Most people who receive this type of care do so for around 1-2 weeks, although short-term care is available for a maximum of six weeks. It will depend on how soon you are able to cope at home. Once you have met your reablement goals, this service will stop.

However, if you have ongoing care and support needs, this will be transferred and delivered through an external domiciliary care agency and may be chargeable. 

Are you able to go home and have no reablement goals?

If you do not have any reablement goals, you will be discharged home on Pathway 1 with a package of care. This care will be delivered by an external Domiciliary Care Agency and may be chargeable from the date you are discharged from hospital.

You will receive a care and support needs assessment (under The Care and Support (Eligibility Criteria) Regulations 2014) from Adult Social Care staff whilst in hospital to determine your care needs. You will be provided with a leaflet -  Guidance Notes - Charging for Non-Residential Care [743KB]  - explaining the charging policy and a referral will be made for a financial assessment to be completed to determine your contribution towards your care costs.

Are you unable to return home?

Most people will be able to return home when they leave hospital.  However, there are occasions when this may not be possible, and you will need to move into a Residential or Nursing Care Home directly from hospital. This is referred to as Pathway 3.

West Berkshire Council have Adult Social Care staff working in the hospitals to help support you in finding the right Care Home to meet your needs.

Moving into a care home is a chargeable service, and you will be financially assessed to determine your contribution towards this cost.  A leaflet -  Guidance Notes - Charging for Residential Care [720KB]  - explaining the charging policy will be provided to you by Adult Social Care staff and a member of the Financial Assessment Team will discuss with you how much you may have to pay.  The care home will be chargeable from the date that you move in. Charging information can be found on our web page Charges for your social care support.