Home Engagement and Rehabilitation Team (HEART)
HEART is our community rehabilitation service that works with people who are in their own accommodation or due to be discharged from inpatient wards.
We help support service users to move on from hospital to the community and are focussed on helping people stay well following discharge - thereby reducing reliance on inpatient services.
We are skilled in helping individuals to work towards their own specific rehabilitation goals. Team members have smaller caseloads and work extended hours, seven days a week, allowing for intensive interventions. We are a time specific service and work with individuals whilst they have active, achievable goals.
We are a multi-disciplinary team and our staff have varied experience, including inpatient rehabilitation and community mental health. We are careful to include service users and carers in planning and reviewing care.
Currently, we cover the geographical areas of Manchester and Salford.
The HEART model offers three distinct pathways:
Transition pathway
HEART hope to support to all service users being discharged from rehabilitation inpatient wards, offering practical and emotional help with the aim of smoothing the move out of hospital, reducing readmission in the early weeks after discharge, and promoting social inclusion.
- We offer approximately 12 weeks in-reach into the ward, and a further 12 weeks support after discharge.
- Care coordination will remain with Community Mental Health Team (CMHT).
- Responsible clinician (RC) responsibility can be with HEART RC from the point of discharge and within the post discharge 12 week period.
- Service users will be referred to HEART by the inpatient rehab units as they approach discharge.
Intervention pathway
We offer in-reach into acute adult wards to work with service users with clear rehabilitation needs, as identified by the host multidisciplinary team (MDT) and supported by occupational therapy (OT) assessment and psychological formulation.
- Care coordination to remain within Community Mental Health Team (CMHT).
- We provide expert assessment, intervention, advice, signposting and recommendations.
- Up to six months period of input (can be extended to 12 months if appropriate).
- Aim to have outcome of assessment within 14 working days.
Hub pathway
For service users with identified longer term rehab needs that can be met in the community.
- HEART provides rehabilitation and recovery interventions in the least restrictive setting.
- Service users will usually move onto the Hub pathway from Transition/Intervention pathway.
- HEART provides care coordination and RC responsibility.
- Support to maintain housing placements and move onto more independent accommodation.
- Two to five year pathway dependent on needs.
We also offer the following services
Out of area placements (OAPs) review
Skilled review of any person placed in rehab OAP (at least six monthly).
No referral required - HEART will keep an overview of rehabilitation OAPs and contact the involved team prior to review.
Advice and consultation
Specialist rehabilitation advice in relation to complex discharges and service users in other Trust services. This will be provided via paper reviews, face-to-face assessments and/or attendance at professionals meetings.
As a service user, relative or carer using our services, sometimes you may need to turn to someone for help, advice, and support.
Find resources for carers and service users Contact the Trust