How to make a referral
To be accepted by the service, people must be:
- Resident of Norfolk and Waveney.
- 18 years or over.
- Either registered with a GP practice in Norfolk and Waveney or willing to be supported to register with a GP practice.
- Being discharged from a hospital bed (community or acute) on Pathway 0 and in need of the service to enable discharge/reduce risk of re-admission OR living in the community and experiencing a crisis or short-term need that could escalate into a more complex issue or a need for statutory services.
- Without sufficient support / not able to support themselves in their place of residence.
- Clinically/medically stable.
- Able to self-mobilise (where the support provided would require this).
We cannot accept:
- People discharged from hospital with an active package of care in place.
- People discharged from hospital with an existing and sufficient support structure. Individuals who have a carer may be supported following discussion with us. This will be to provide short-term support. Respite is not provided.
- Those returning to, or currently in, a care setting, including home care and domiciliary care.
- Those who have complex needs, e.g.
- Dependency issues (drugs, alcohol)
- Hoarding (above level 3 on the Clutter scale)
- Mental health conditions that are more than low-level
- Dementia beyond mild cognitive decline
- Requirement for CQC regulated care, i.e. personal care
- Respite support
Referrals can be refused following a risk assessment.