Complex transition support service – ICB Case Management

We help people with support needs that are complex, who are currently in an NHS or independent hospital setting, helping them to transition to community placements. The people we work with are clinically ready to leave hospital and are referred to our service by the integrated care board (ICB) or system partners.

We help people move out of hospital and into services in the community. To do this, we work closely with the NHS, local authorities, and community service partners.

Our case management support includes:

• Exploring and gathering information about the kind of support the person needs.
• Finding community providers that could support them.
• Taking applications through ICB funding panels.
• Planning for their move into that service, and helping to make sure the move goes smoothly
• Supporting the person and their new provider for 12 weeks after they move out of hospital.

We can join care planning meetings with or on behalf of the people we’re supporting, we’ll check in at least every 6 weeks, and we’ll make sure that the views and hopes of the people we support on their move from hospital are listened to and considered by everyone.

Our team of qualified practitioners, nurses, and occupational therapists work together to manage the caseload and provide clinical case management.

We also have nurse support practitioners, who provide extra support to our team. Our case managers focus on specific areas and/or population groups, and the service is managed by our specialist service lead.