Getting clients home following a period of intensive rehabilitation is a priority for the team at STEPS Rehabilitation. Improving a person’s mental and physical condition to put them in a position to do this, brings focus and a purpose to the rehabilitation process.

In this article, we speak with Jennie Foster, Transition of Care Lead at STEPS Rehabilitation about her role in helping clients through this part of their rehabilitation journey.

We talk about what we need to do in order to get a client home, often before they have even arrived at STEPS!” explains Jennie. “The majority of clients are focused on getting home too. Before coming to STEPS for intensive rehabilitation, many of them have spent long periods of time in hospital already, and whilst STEPS offers a unique ‘home-like’ environment, we all know that there is no place like home.”

Jennie qualified in 2017 with a combined degree in Nursing and Social Work at Sheffield Hallam University. During her final term, Jennie worked at STEPS as a Senior Rehabilitation Assistant, and following qualification, she joined full-time as a nurse. She works clinical shifts as a nurse, and on non-clinical days as a social worker. Her nursing and social working expertise means she’s perfectly placed to support clients and their families with their discharge planning.

What does your role as Transition of Care Lead involve?

“In short, I do whatever is needed to help clients in their transition from STEPS to home. A big part of my role involves liaising with community teams and case managers to ensure that a client’s transition home is a smooth as possible and that everything is in place to enable them to continue to flourish and reach their full potential.

This includes undertaking any Mental Health Act Assessments (MCAs) around their care and treatment, as well as completing any Deprivation of Liberty Safeguards (DoLS) that may arise.”

Jennie is responsible for coordinating all the referrals for the community services required by a person following discharge. For example, liaising with district nurses, physiotherapists, occupational therapists, speech and language therapists, dieticians and psychologists to ensure a client has all the ongoing care and support that they need.

It’s both an exciting and scary time for clients” says Jennie. “Whist at STEPS clients are focused on their rehabilitation and getting better. They have a routine, as well as social distractions. They are surrounded by not just medical specialists, but other people going through a similar experience.

Leaving this nurturing and comfortable environment can often feel daunting, so I spend time talking to clients and their families about what life might look like once they are back home. They have a role and purposes, whether that’s as a parent or a spouse.”

Funding ongoing care

Jennie is also responsible for completing the Continuity Healthcare Checklist (CHC) which screens whether someone is eligible for funding. If they are she will work with the CHC team, social workers, families and clients to complete the Decision Support Tool (DST) which decides whether a person will receive healthcare or social care funding, or a joint package.

“I also help clients with their benefit applications. It can be a minefield navigating your way around the benefit system and establishing eligibility criteria. This is an added stress for clients, at an already stressful time, so being in a position to alleviate some of that stress is rewarding.”

STEPS Training School

STEPS Rehabilitation clients invariably have very complex needs and require significant ongoing care involving a multi-disciplinary approach. Jennie’s role is to coordinate and establish a team who will be responsible for caring for clients once they return home.

This need has led to creation of STEPS Training School - a unique service that works with the client’s new team to fully train and advise them about a client’s condition, as well as their rehabilitation and living needs. The aim is to ensure a smooth transition whilst maintaining a high-quality care regime.

What made you want to pursue a career in neuro rehab?

“Whilst on a placement during my training I met a man in his 30’s who had suffered a brain injury as a teenager after he fell from his bike. His notes were littered with various labels, referring to him having ‘learning disabilities’ or being ‘uncommunicative’. After spending time with him, I realised this wasn’t the case at all, he just hadn’t been given the right tools or support to allow him to communicate. I thought, “this man just needs an advocate…someone who can support him.” I ended up helping him to get some assistive technology that enabled him to communicate, and it changed how he interacted with the world.”

“I love my job and see it as a privilege to be able to spend time with clients, hear their stories and being their voice when they often struggle to be heard.”