For discharge coordinators and transfer of care teams
Getting someone home, and keeping them there
A discharge that fails within a fortnight costs more than one that took a few days longer to arrange properly. This page sets out how fast we can realistically move, what we need from the ward, and what we do in the first two weeks.
Referrals line: REFERRALS PHONE · Referrals inbox: REFERRALS EMAIL
This page is for you if
You are trying to discharge someone who needs a care package or a supported living placement, and you need a provider who will commit to a date and then hold it.
We would rather give you a slower date we can keep than a faster one we cannot. If we say a team will be ready on Thursday, that means the staff are recruited, trained on this person, and rostered — not that we hope to be.
The first fortnight is where readmissions happen. We treat it as part of the placement, not as the end of it.
What we can take, and what we would decline
We would expect to be able to help with
- Supported living with a tenancy, with support hours matched to assessed need
- Live-in and visiting care in a person’s own home
- CONFIRM STAFFING PATTERNS: 1:1, 2:1, waking night, sleep-in
- CONFIRM AGE RANGE SUPPORTED
- CONFIRM: autism, learning disability, mental health, complex and forensic needs
We would be honest and decline where
- The environment or the existing tenant group would make a safe placement unlikely
- The support hours funded would not meet the assessed level of risk
- CONFIRM EXCLUSIONS — what Bellus would not accept
- We cannot recruit and train the right team in the timescale you need
- A better-matched provider already exists and we would be the wrong answer
Saying no early is more useful to you than saying yes slowly. We would rather decline a referral in the first conversation than hold up a discharge or a placement while we work out that we cannot do it.
What we need to review a referral properly
- A current needs assessment, or the most recent one available
- Any risk assessment and positive behaviour support plan in place
- Relevant health information, including diagnoses and prescribed medication
- Capacity and best-interests decisions relevant to accommodation and care
- Any DoLS, Court of Protection order or Section 117 aftercare status
- The funding route and the authority or team holding the budget
- Communication needs, sensory needs and known triggers
- Who else is involved — family, advocate, care coordinator, current provider
- Planned or estimated discharge date
- Equipment ordered, and whether it will be in place before the move
- Any therapy input continuing after discharge
Send what you have. An incomplete referral still gets a response — we will tell you what else we need rather than sitting on it. Documents can be uploaded securely through the referral form (accepted formats and size limits are shown on the upload step).
Funding arrangements we work with
Local authority
CONFIRM: adult social care funded packages, including joint and pooled arrangements.
NHS Continuing Healthcare
CONFIRM: CHC-funded placements and jointly funded packages.
Section 117 aftercare
CONFIRM: aftercare packages following detention under the Mental Health Act.
Personal health budgets
CONFIRM: PHBs and direct payments, including where a family manages the budget.
Private / self-funded
CONFIRM: privately funded arrangements and deputy-managed funds.
Frameworks and DPS
CONFIRM WHICH FRAMEWORKS AND DYNAMIC PURCHASING SYSTEMS BELLUS IS ON.
Every item on this page marked in amber is awaiting confirmation from Bellus and is not yet a published commitment.
What happens after you send a referral
- 1
Initial discussion
A short conversation about the person’s needs and current situation, so we can tell you early whether Bellus is a realistic option. No paperwork required to start this.
- 2
Referral and documents
Formal submission through our secure form, with supporting documents attached.
- 3
Information review
Our clinical and operational teams review the documentation to confirm whether we can safely meet the person’s needs.
- 4
Specialist assessment
A face-to-face or virtual assessment with the person, their family and any current provider.
- 5
MDT review
Our internal multidisciplinary team formulates a support strategy and confirms whether we can offer a safe, effective placement.
- 6
Compatibility assessment
For supported living, a formal assessment of compatibility with existing tenants, the environment and the local community.
- 7
Funding and placement proposal
Detailed costings, a proposed support plan and a transition proposal, submitted to you.
- 8
Transition planning
A step-by-step plan including familiarisation visits, person-specific staff training and any environmental adaptations.
- 9
Move-in
Support commences with a team that has already been trained and briefed on this person.
- 10
Reviews
A structured initial review, then ongoing outcome reviews focused on quality of life, not just service delivery. CONFIRM REVIEW INTERVALS
We publish this pathway because transparency is worth more to a commissioner than a brochure. If a step is going to take longer than expected, we will tell you rather than let the referral go quiet.
What you can expect from us, and when
SLA 1
Initial clinical and operational review, and a clear yes or no on whether we are pursuing the referral.
SLA 2
Specialist assessment arranged with the person and everyone who needs to be there.
SLA 3
Placement proposal and full costings submitted to the funding authority.
These commitments are pending confirmation by Bellus. We will not publish a response time the service cannot operationally hold — a broken commitment costs more than an unpublished one. Out-of-hours referral route: OUT-OF-HOURS ROUTE
Questions from discharge teams
1What is the fastest you can start a package?
CONFIRM EMERGENCY AND PLANNED START TIMEFRAMES. We will give you a date we can hold rather than the earliest one that sounds good.
2Can you start a package before equipment arrives?
Sometimes, depending on what the equipment is for. We will tell you honestly whether the package is safe without it.
3Do you attend discharge planning meetings?
Yes, and usually the earlier the better — it is the fastest way to establish whether a placement is realistic.
4What if the person deteriorates before discharge?
Tell us. A referral we have already reviewed can be re-reviewed quickly; a surprise on move-in day cannot.
5Who covers out of hours in the first week?
OUT-OF-HOURS ROUTE.
Talk to us about a person you are trying to place
A short conversation before a formal referral usually saves everyone time. Tell us the situation and we will give you a straight answer about whether Bellus is a realistic option.
Referrals inbox: REFERRALS EMAIL · General enquiries: [email protected]