Introduction

We have four Health Interface Service (HIS) teams across Somerset. They are Adult Social Care teams that work alongside other people from a variety of settings. For example, hospitals, community, voluntary organisations and providers. This is to support people to be discharged at the right time. Older people who stay longer in hospital than necessary are vulnerable to complications such as hospital acquired infections, falls, muscle wastage and a reduction in their independence. The Health Interface Service works alongside the Somerset Home First discharge model. This model helps people to return to their own home with reablement support. Or for a short-term stay in a reablement unit prior to returning home.

The Health Interface Service also works with Rapid Response and provides a social care service in the Emergency Departments in Somerset to try and prevent people going into hospital unnecessarily.

Each team has Social Workers, Adult Social Care Workers, Occupational Therapists and Community Agents. Other support, for example from a District Nurse, Physiotherapist, Carers Support Worker or support from staff skilled in mental health issues, can also be arranged if you need them.

What will happen

If you are in hospital and it is identified that you would benefit from support upon discharge, someone from Health Interface Service or the Home First team will talk with you, and your family, so we can understand your situation.

• For most people, the information and advice they provide is all you need.
• For some people, providing short-term support in your home will, as you recover, help you to do the things again that you were temporarily unable to do.
• For some people, a short-stay in a reablement unit or care home may be the best solution, until you are ready to return home. And for some people, longer-term care and support may be what you need. Whether this is in your home or other kinds of housing.

We will discuss the options with you and then, if you can, leave you to make your own arrangements. Or if you are eligible, we can organise the short-term care and support you need while you recover.

What we will talk about

These are some of the things we will talk about:

• Things you want to do that matter most to you
• The support you need to do things you want to do
• Things you would like to change
• Things you are worried about

What we will do

This will depend on the conversation and will be tailored to you. Here are some of the things that the team could do:

• Provide you with good advice and information
• Develop a care and support plan with you, listing things you want to achieve
• Agree with you how you will achieve these things in manageable stages
• Give advice about, or sometimes provide, equipment if it is needed
• Arrange the things we have agreed to do in your care and support plan
• Work closely with other organisations who are involved with your care

Carer support

If you have someone who helps you, or a friend or neighbour who supports you, it might be helpful to have them with you when we visit if you wish.

It is important that they know about your care and support plan and how they can best help you. We would also be able to provide your carer with their own assessment, support plan and with some support if they need it.

How long you will be supported

Home First is a free and time limited service which is only provided for a period based on individual need. The free element of the service will not be provided for longer than six weeks, but the aim is to reable people to their full potential is a much shorter time frame than that.

If you need support for longer than six weeks, or it is agreed that you have ongoing needs then these will be taken into account in your Care Act assessment.

If you need longer-term support from Social Care to help you pay for your care and support, you will need to meet the national eligibility criteria and have no more than £23,250 in capital and savings. We will then ask someone from our Financial Assessment and Benefits (FAB) team to arrange to visit you.

They will make sure you are receiving all the benefits you are entitled to so that you have enough money to live on and help you to fill in benefit claim forms, if you would like them to. They will also talk to you about your capital and income and work out what contribution, if any, you will need to make towards any ongoing support you need