Support leaving hospital (Joint Care Pathway)

In West Berkshire, the Berkshire NHS Intermediate Care Team and West Berkshire Council Adult Social Care work together to support people being discharged from hospital.

Our Joint Care Pathway (JCP) Team organises goal-focused, short-term care and support to help adults get back their independence after being in hospital. This is known as 'intermediate care' or 'reablement'.

If you can go home with reablement goals

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

Reablement support is provided by a team of people. The team will discuss and identify realistic aims for you to work towards during your time with the service. Reablement support normally lasts around 1 to 2 weeks. It may last longer, but no more than 6 weeks. The length of care will depend on how quickly you can cope at home. Once you have met your reablement goals, this service will stop.

You may work with an occupational therapist, physiotherapist, therapy assistant or a Reablement officer to arrange your goals. Reablement care will be provided by a care agency or reablement carers.

Following reablement, if you need long-term support, we will arrange for a care and support needs assessment to work out how your needs will be met. If you need ongoing care and support, there will be a charge for care services.

If you can go home with a package of care

If hospital staff assess that you can go home but you need further care at home, you will be discharged home on Pathway 1 with a package of care and no reablement goals. You will receive a care and support needs assessment from Adult Social Care staff whilst in hospital to work out your care needs.

This care will be delivered by a home care agency. There will be a charge for this care from the date you are discharged. You will be referred for a financial assessment to decide how much you will pay towards your care costs. You can find out more about paying for your care here.

If you cannot go home

Most people will be able to go home when they leave hospital. However, there are times when this may not be possible, and you need to move from hospital to a residential or nursing care home. This is referred to as Pathway 3.

Adult Social Care staff can work with you in hospital to help you find a care home to meet your needs.

There will be a charge for the residential or nursing care home from the date you are discharged by the hospital. You will have to pay towards the cost of this. You will be referred for a financial assessment to decide how much you will pay towards your care costs. You can find out more about paying for your care here.