Hospital discharge, support at home and reablement in Sandwell
A Sandwell guide to short-term assessment and reablement after illness or hospital discharge, including STAR support, referral routes and when longer-term care may follow.

One of the most practical parts of Sandwell’s local adult social care offer is the short-term support available when someone is leaving hospital or is at risk of admission. These services are designed to help people recover safely, rebuild daily living skills and avoid moving straight into long-term care before they have had the chance to regain independence.

What Sandwell means by support at home

Sandwell’s published guidance says its home support services work with adults, including older people and older people with mental health needs, for short periods of time following hospital discharge and to help avoid hospital admission. The aim is to make sure the person is safe and support them to be as independent as possible in their own home.

The STAR service

Sandwell specifically names its STAR (Short-Term Assessment and Reablement) service as the borough’s reablement offer. The service is delivered in the person’s own home and is intended to improve daily living skills so that people can live independently again. In practice, this can mean relearning routines, building confidence after illness, testing what support is really needed, and avoiding long-term over-support where recovery is possible.

How people are referred

Sandwell says referrals usually come through a health or social care professional. If you are already in hospital, ward staff can help with that process. If you are at home, the council’s public pages suggest talking to your GP, district nurse or adult social care. Family members and friends can also contact Adult Social Care if they think someone would benefit.

What is free and what is not

Sandwell’s charging guidance says intermediate care and rehabilitation services are free. That includes the short-term recovery services the council uses to help people after illness or discharge. If, however, the short-term work shows that someone needs a longer-term package of support, the borough may then move on to a full care assessment, support planning and a financial assessment for any ongoing chargeable care.

Other support that may be part of the plan

Sandwell’s broader ‘get help and support at home’ pages show that support at home can sit alongside equipment and adaptations, community alarms, day opportunities, meals, personal assistants, extra care housing or other community-based services. If you prefer to arrange some support yourself, the borough also points residents to the Information Point directory.

When to ask for more help

If the person is not coping after discharge, is at risk of a fall, cannot manage medication, is unsafe alone or the main carer is struggling to continue, do not wait for the situation to worsen. Contact Sandwell Adult Social Care, speak to the district nursing team, or raise it with the ward or discharge team while the person is still in hospital.

Useful Sandwell links

Last reviewed: 30 March 2026. Opening times, charges, referral routes, eligibility rules and commissioned services can change, so always use the linked Sandwell or NHS service before you travel, apply or rely on a phone number.

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Author: telsolutions

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