BNSSG Healthier Together

This pathway is for people who are well enough to leave hospital but still need some support to regain independence before they can return to the place they call home.

You will transfer for a short stay in a community rehabilitation bed to continue your rehabilitation (rehab for short) and recovery. This may be in a rehabilitation unit or a care home that includes therapy support. We try to ensure you are as close to home as possible but this may not always be possible, particularly if you have specialist needs.

Read more about this pathway below, or download our leaflet on rehab to home.

What to expect

When you arrive, you will be welcomed by the team caring for you. They will check how you are and agree a plan for your medical and nursing care.

You will see a therapist who will assess your rehabilitation needs. They will work with you to understand your personal goals and to develop your rehabilitation plan.

We use everyday activities, like getting dressed or walking to the bathroom, alongside exercise plans to support your individual rehabilitation.

The team caring for you will work with you throughout each day to support your rehabilitation plan, making sure you have opportunities to move around and do things for yourself.

It is really important you work with us and take every opportunity to progress towards your rehabilitation goals.

How long will I stay?

This is a short-term service while we support you to be as independent as possible before you return to the place you usually live.

Early in your stay, we will identify the date we think you should be ready to leave and start planning your discharge with you and your family or carers.

We will assess your progress regularly, so this date may change. You and your family will be involved in all discussions around this date and what further support you may need when you leave.

What happens when I’m ready to leave?

When you are ready to leave, you may be able to go back to the place you call home without any further support.

If you require further support at home, this may be provided by our community therapy team or the local authority social care team. If home isn’t the best place for you, we will discuss alternative locations with you and your family that may be more suitable for your
ongoing needs.

If you need longer term support, your local authority social care team will assess your needs and discuss these with you, your family and carers. At this point, a financial assessment may be made and you may need to pay towards any social care you receive.