Support after leaving hospital or if you are in recovery

If you need

• support following discharge from hospital
• support in the community whilst recovering from an injury or illness 
• support that prevents or reduces the need for long term care, allowing people to remain in their own homes

Our Technology Enabled Care and Reablement Intervention (TRI) team can provide a short-term service, usually up to six weeks. 

You will be assigned a keyworker from the TRI team who will complete an initial assessment and identify a set of goals. 

Typical support may include

• technology enabled and remote care provision
• provision and trial of telecare devices such as falls detectors, memory aids and monitoring systems 
• in-person reablement care visits
• a short period in a care home (residential reablement) 
• adaptive equipment and aids for daily living 

Referrals to TRI can be made by

• Social workers, Occupational Therapists or Adult Social Care workers from North Somerset Council adult social care teams
• Therapists working in Discharge to Assess (D2A) pathways within Sirona
• Healthcare professionals working in the Transfer of Care hubs at either UHBW or NBT hospital trusts

To receive support from the TRI team, a person will need to

1.  consent to a referral and
2.  be able to participate in goal setting (with an advocate if needed). 

Cost and timeline of support

Support provided by the TRI team

1. is free (up to 42 days for domiciliary and residential reablement providers)
2. is not assessed against the Care Act eligibility criteria

Who cannot access this support

The team are unable to work with people who

• are under the age of 18
• require specialist support services for example through Mental Health or Learning Disability Teams
• require specialist rehabilitation services, for example stroke, brain injury and spinal rehabilitation
• require a rapid response, urgent care or support to avoid hospital admission
• are eligible for CHC or Section 117 support

Once a person has achieved their goals (or support is no longer required) then they will be discharged from the service. 

If a person still has needs identified following TRI Team input, then a referral for a social care assessment will be made to the appropriate team to complete and provide ongoing care support. 

Anyone who would usually self-fund their support and who doesn’t wish to have an assessment will be given the option for a referral to the care navigator service.