Our detailed assessment can take place where it best suits the service user, so we can begin to understand the complexity of the need and type of support and care package required. We recognise the need to be flexible and have an approach which meets the needs of the individual. We will work in partnership with the MDT team (e.g. psychiatry, psychology, OT, SALT etc) to optimise care and rehabilitation provision.
Within the rehabilitation and care/support plan, there will be clear evidence-based journey plans. Which can include Social integration support, crisis and stress management, community support groups, goal setting, financial and work support, advocacy services, educational opportunities, health, and well-being support.
The rehabilitation plan will be put together with the support of the MDT, the Individual and NursLink, identifying outcomes against the treatment will be measured and recorded to support rehabilitation outcomes. This is to optimise the individual’s abilities to facilitate their progress towards increased autonomy and their identified least restrictive plan.
