Referral and Assessment
- Exemplar Health Care clinician take a patient history and reviews needs.
- Pre-administration assessment completed including agreement of objectives and goals.
- Review community fit with preferred home and share formal assessment report and costings with funders.
Admission and placement
- Agree goals and timescales in a detailed personalised Care Plan.
- Review Care Plan after six weeks to ensure desired outcomes are on track.
- Review of progress against Care Plan every six months.
Discharge and pathway planning
- Review progress against expected outcome and plan discharge.
- Explore options including transition to OneCare services and discharge into the community.
- Working with service users, families and funders, agree a discharge and transition plan.