Hospital Disharge and Hospital Prevention

Descriptions

We are recommissioning a hospital prevention and discharge service designed to help individuals remain or resettle in their own homes after hospital admission. This is a preventative service that does not require CIW registration and will not provide formal care. It aims to support people over the age of 50 living in Monmouthshire who lack suitable family or community support. The service will operate five to seven days a week and provide short-term interventions to enable safe hospital discharge or prevent admission. It will work closely with social care teams, hospital discharge teams, and community healthcare professionals across Monmouthshire hospitals and other local hospitals, including Royal Gwent and The Grange. Referrals may also come from community healthcare teams managing individuals at risk of admission. Support will focus on practical assistance and signposting. This includes helping individuals organize online shopping, access transport, and connect with community resources. Once immediate needs are met, the service will encourage social engagement and financial stability by facilitating benefit checks, linking to third-sector organisations, and arranging services such as Meals on Wheels. Successful provider must have strong knowledge of local resources and voluntary sector support. Although primarily delivered face-to-face, the service will include follow-up phone calls and emails to monitor progress and make referrals where necessary.

Engagement

We are now inviting written comments from the market on the proposed service which will support us in shaping the service specification and future direction of the service. This written market engagement will be followed by an online event with further information to follow. Questions 1. What sort of service do you believe would meet the needs of this client group? 2. Within the estimated contract value what do you see the service looking like? Do you see it as achievable? 3. Are you aware of any examples of best practice or innovations in this area, or similar areas that could be applied here?